Bundle A1 Chronic Disease Management: Diabetes Care - HHSC



DSRIP Category CMeasure Specifications: DY7-8Part 2 of 4: Hospital and Physician Practice SpecificationsContents TOC \o "1-3" \h \z \u Bundle A1 Chronic Disease Management: Diabetes Care PAGEREF _Toc504410693 \h 2Bundle A2 Improved Chronic Disease Management: Heart Disease PAGEREF _Toc504410694 \h 29Bundle B1 Care Transitions & Hospital Readmissions PAGEREF _Toc504410695 \h 57Bundle B2 Patient Navigation & ED Diversion PAGEREF _Toc504410696 \h 80Bundle C1 Primary Care Prevention - Healthy Texans PAGEREF _Toc504410697 \h 89Bundle C2 Primary Care Prevention - Cancer Screening PAGEREF _Toc504410698 \h 124Bundle C3 Hepatitis C PAGEREF _Toc504410699 \h 136Bundle D1 Pediatric Primary Care PAGEREF _Toc504410700 \h 147Bundle D3 Pediatric Hospital Safety PAGEREF _Toc504410701 \h 186Bundle D4 Pediatric Chronic Disease Management: Asthma PAGEREF _Toc504410702 \h 198Bundle D5 Pediatric Chronic Disease Management: Diabetes PAGEREF _Toc504410703 \h 210Bundle E1 Improved Maternal Care PAGEREF _Toc504410704 \h 220Bundle E2 Maternal Safety PAGEREF _Toc504410705 \h 234Bundle F1 Improved Access to Adult Dental Care PAGEREF _Toc504410706 \h 256Bundle F2 Preventive Pediatric Dental PAGEREF _Toc504410707 \h 268Bundle G1 Palliative Care PAGEREF _Toc504410708 \h 273Bundle H1 Integration of Behavioral Health in a Primary or Specialty Care Setting PAGEREF _Toc504410709 \h 294Bundle H2 Behavioral Health and Appropriate Utilization PAGEREF _Toc504410710 \h 313Bundle H3 Chronic Non-Malignant Pain Management PAGEREF _Toc504410711 \h 337Bundle H4 Integrated Care for People with Serious Mental Illness PAGEREF _Toc504410712 \h 359Bundle I1 Specialty Care PAGEREF _Toc504410713 \h 370Bundle J1 Hospital Safety PAGEREF _Toc504410714 \h 375Bundle K1 Rural Preventive Care PAGEREF _Toc504410715 \h 390Bundle K2 Rural Emergency Care PAGEREF _Toc504410716 \h 426Bundle A1 Chronic Disease Management: Diabetes CareMeasure Bundle ObjectivesDevelop and implement chronic disease management interventions that are geared toward improving management of diabetes and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.Target PopulationAdults ages 18 - 75 at the start of the measurement period with a diagnosis of Type 1 or Type 2 diabetes that meet the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement period(Diabetes Values: 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, O24.83) Exclude individuals enrolled in hospice during the measurement year. Related System ComponentsRequired Measures: Outpatient primary care, relevant outpatient specialty care where diabetes is managedMPT of 75 Requires ED, inpatientMPT below 75 requires ED and inpatient if availableNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesA1-111: Comprehensive Diabetes Care: Eye Exam (retinal) performedMeasure Description:Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement periodA1-111: Comprehensive Diabetes Care: Eye Exam (retinal) performedDY7/DY8 Program IDA1-111Measure DetailsSteward: NCQANQF #: 0055Source: CMS MIPS #117 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptional with additional points if selectedMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.6807MPL: 0.4453National 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 of will be 61.50% and DY8 goal will be 62.16%.Denominator DescriptionPatients 18 - 75 years of age with diabetes with a visit during the measurement periodDenominator 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 the performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 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" "Encounter, Performed: Ophthalmological Services" during "Measurement Period"NOTE: Providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219, 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 is using hospice services any time during the measurement period: G9714 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 with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal or dilated eye exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period NUMERATOR NOTE: The eye exam must be performed or reviewed by an ophthalmologist or optometrist. Alternatively, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.Numerator Inclusions (Performance Met)CLAIMS/REGISTRY:Dilated retinal eye exam with interpretation by an ophthalmologist or optometrist documented and reviewed (2022F)ORSeven standard field stereoscopic photos with interpretation by an ophthalmologist or optometrist documented and reviewed (2024F)ORPerformance Met: Eye imaging validated to match diagnosis fromseven standard field stereoscopic photos results documented and reviewed (2026F)ORPerformance Met: Low risk for retinopathy (no evidence of retinopathy in the prior year)* (3072F)*Note: This code can only be used if the claim/encounter was during the measurement period because it indicates that the patient had “no evidence of retinopathy in the prior year”. This code definition indicates results were negative; therefore a result is not required. E.H.R.: AND: "Physical Exam, Performed: Retinal or Dilated Eye Exam" satisfies any: (result: Negative Finding) < 12 month(s) ends before start of "Measurement Period" during "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Dilated eye exam was not performed, reason not otherwise specified (2022F or 2024F or 2026F with 8P) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationE.H.R.:Data 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: 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-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: Retinal or Dilated Eye Exam" using "Retinal or Dilated Eye Exam Grouping Value Set (2.16.840.1.113883.3.464.1003.115.12.1088)"? 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)"? Attribute: "Result: Negative Finding" using "Negative Finding Grouping Value Set (2.16.840.1.113883.3.464.1003.195.12.1002)"A1-112: Comprehensive Diabetes Care: Foot ExamMeasure Description:The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year.A1-112: Comprehensive Diabetes Care: Foot ExamDY7/DY8 Program IDA1-112Measure DetailsSteward: NCQANQF #: 0056Source: CMS MIPS #163 (Claims/Registry) eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionPatients 18-75 years of age with diabetes with a visit during the measurement periodExclusions: Patients who have had either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period.Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: "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"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 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: Bilateral amputation of leg below or above knee" starts before or concurrent with end of "Measurement Period" OR: AND: Union of: "Diagnosis: Right Unilateral Amputation Above or Below Knee" "Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality (anatomical location site: Right)" starts before or concurrent with end of "Measurement Period" AND: Union of: "Diagnosis: Left Unilateral Amputation Above or Below Knee" "Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality (anatomical location site: Left)" starts before or concurrent with end of "Measurement Period"Numerator DescriptionPatients who received a foot exam (visual inspection and sensory exam with monofilament and pulse exam) during the measurement year.Numerator Inclusions (Performance Met)AND: "Physical Exam, Performed: Visual Exam of Foot" during "Measurement Period"AND: "Physical Exam, Performed: Sensory Exam of Foot" during "Measurement Period"AND: "Physical Exam, Performed: Pulse Exam of Foot" during "Measurement Period"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included. Data Criteria (QDM Data Elements):? "Diagnosis: Bilateral amputation of leg below or above knee" using "Bilateral amputation of leg below or above knee Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1056)"? "Diagnosis: Diabetes" using "Diabetes Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1001)"? "Diagnosis: Left Unilateral Amputation Above or Below Knee" using "Left Unilateral Amputation Above or Below Knee Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1058)"? "Diagnosis: Right Unilateral Amputation Above or Below Knee" using "Right Unilateral Amputation Above or Below Knee Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1057)"? "Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality" using "Unilateral Amputation Below or Above Knee, Unspecified Laterality Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1059)"? "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)"? "Physical Exam, Performed: Pulse Exam of Foot" using "Pulse Exam of Foot Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1015)"? "Physical Exam, Performed: Sensory Exam of Foot" using "Sensory Exam of Foot Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1014)"? "Physical Exam, Performed: Visual Exam of Foot" using "Visual Exam of Foot Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1013)"? 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)"A1-115: 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.A1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)DY7/DY8 Program IDA1-115Measure DetailsSteward: NCQANQF #: 0059Source: CMS MIPS #1 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 periodDenominator 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"NOTE: Providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219, 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: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 Instructions:INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control. Patient is numerator compliant if most recent HbA1c level >9% or is missing a result or if an HbA1c test was not done during the measurement year. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance.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 InformationE.H.R.:Data 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)"A1-207: 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.A1-207: Diabetes care: BP control (<140/90mm Hg)DY7/DY8 Program IDA1-207Measure DetailsSteward: NCQANQF #: 0061Source: See notesData SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 the 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"NOTE: Providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219, 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:Patients who use hospice services any time during the measurement period: G9715E.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)CLAIMS: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 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 InformationFor E.H.R. measurement, providers should refer to the value sets included in measures A1-115 and A2-103 for OIDs of referenced value sets. A1-500: PQI 93 Diabetes Composite (Adult short-term complications, long-term complications, uncontrolled diabetes, lower-extremity amputation admission rates)Measure Description:Prevention Quality Indicators (PQI) composite of diabetes admissions per 100,000 population, ages 18 years and older. Includes admissions for one of the following conditions: diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation.A1-500: PQI 93 Diabetes Composite (Adult short-term complications, long-term complications, uncontrolled diabetes, lower-extremity amputation admission rates)DY7/DY8 Program IDA1-500Measure DetailsSteward: AHRQNQF #: NASource: AHRQ: SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionDischarges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs:? PQI #1 Diabetes Short-Term Complications Admission Rate? PQI #3 Diabetes Long-Term Complications Admission Rate? PQI #14 Uncontrolled Diabetes Admission Rate? PQI #16 Lower-Extremity Amputation among Patients with Diabetes RateDischarges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.Numerator Inclusions (Performance Met)PQI #1: Diabetes Short Term Complications: Discharges, for patients ages 18 years and older, with a principal ICD-10-CM diagnosis code for diabetes shorttermcomplications (ketoacidosis, hyperosmolarity, or coma) E1010 Type 1 diabetes mellitus with ketoacidosis without comaE1011 Type 1 diabetes mellitus with ketoacidosis with comaE10641 Type 1 diabetes mellitus with hypoglycemia with comaE1100 Type 2 diabetes mellitus with hyperosmolarity without nonketotichyperglycemic-hyperosmolar coma (NKHHC)E1101 Type 2 diabetes mellitus with hyperosmolarity with comaE11641 Type 2 diabetes mellitus with hypoglycemia with coma PQI #3 Diabetes Long Term Complications Admission rateDischarges, for patients ages 18 years and older, with a principal ICD-10-CM diagnosis code for diabetes with long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified).E1021: Type 1 diabetes mellitus with diabetic nephropathyE1022: Type 1 diabetes mellitus with diabetic chronic kidney diseaseE1029: Type 1 diabetes mellitus with other diabetic kidney complicationE10311: Type 1 diabetes mellitus with unspecified diabetic retinopathy with macular edemaE10319: Type 1 diabetes mellitus with unspecified diabetic retinopathy without macular edemaE10321: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edemaE103211: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eyeE103212: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eyeE103213: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateralE103219: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eyeE10329: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edemaE103291: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eyeE103292: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eyeE103293: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateralE103299: Type 1 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eyeE10331: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edemaE103311: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eyeE103312: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eyeE103313: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateralE103319: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eyeE10339: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edemaE103391: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eyeE103392: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eyeE103393: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateralE103399: Type 1 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eyeE10341: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edemaE103411: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eyeE103412: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eyeE103413: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateralE103419: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eyeE10349: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edemaE103491: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eyeE103492: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eyeE103493: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateralE103499: Type 1 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eyeE10351: Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edemaE103511: Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eyeE103512: Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eyeE103513: Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateralE103519: Type 1 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eyeE103521: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eyeE103522: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eyeE103523: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateralE103529: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eyeE103531: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eyeE103532: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eyeE103533: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateralE103539: Type 1 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eyeE103541: Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eyeE103542: Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eyeE103543: Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateralE103549: Type 1 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eyeE103551: Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, right eyeE103552: Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, left eyeE103553: Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, bilateralE103559: Type 1 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eyeE10359: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edemaE103591: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eyeE103592: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eyeE103593: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateralE103599: Type 1 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eyeE1036: Type 1 diabetes mellitus with diabetic cataractE1037X1: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, right eyeE1037X2: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, left eyeE1037X3: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateralE1037X9: Type 1 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eyeE1039: Type 1 diabetes mellitus with other diabetic ophthalmic complicationE1040: Type 1 diabetes mellitus with diabetic neuropathy, unspecifiedE1041: Type 1 diabetes mellitus with diabetic mononeuropathyE1042: Type 1 diabetes mellitus with diabetic polyneuropathyE1043: Type 1 diabetes mellitus with diabetic autonomic (poly)neuropathyE1044: Type 1 diabetes mellitus with diabetic amyotrophyE1049: Type 1 diabetes mellitus with other diabetic neurological complicationE1051: Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangreneE1052: Type 1 diabetes mellitus with diabetic peripheral angiopathy with gangreneE1059: Type 1 diabetes mellitus with other circulatory complicationsE10610: Type 1 diabetes mellitus with diabetic neuropathic arthropathyE10618: Type 1 diabetes mellitus with other diabetic arthropathyE10620: Type 1 diabetes mellitus with diabetic dermatitisE10621: Type 1 diabetes mellitus with foot ulcerE10622: Type 1 diabetes mellitus with other skin ulcerE10628: Type 1 diabetes mellitus with other skin complicationsE10630: Type 1 diabetes mellitus with periodontal diseaseE10638: Type 1 diabetes mellitus with other oral complicationsE1069: Type 1 diabetes mellitus with other specified complicationE108: Type 1 diabetes mellitus with unspecified complicationsE1121: Type 2 diabetes mellitus with diabetic nephropathyE1122: Type 2 diabetes mellitus with diabetic chronic kidney diseaseE1129: Type 2 diabetes mellitus with other diabetic kidney complicationE11311: Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edemaE11319: Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edemaE11321: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edemaE113211: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, right eyeE113212: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, left eyeE113213: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, bilateralE113219: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy with macular edema, unspecified eyeE11329: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edemaE113291: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, right eyeE113292: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, left eyeE113293: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, bilateralE113299: Type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema, unspecified eyeE11331: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edemaE113311: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, right eyeE113312: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, left eyeE113313: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, bilateralE113319: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy with macular edema, unspecified eyeE11339: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edemaE113391: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, right eyeE113392: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, left eyeE113393: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, bilateralE113399: Type 2 diabetes mellitus with moderate nonproliferative diabetic retinopathy without macular edema, unspecified eyeE11341: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edemaE113411: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, right eyeE113412: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, left eyeE113413: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, bilateralE113419: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy with macular edema, unspecified eyeE11349: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edemaE113491: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, right eyeE113492: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, left eyeE113493: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, bilateralE113499: Type 2 diabetes mellitus with severe nonproliferative diabetic retinopathy without macular edema, unspecified eyeE11351: Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edemaE113511: Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, right eyeE113512: Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, left eyeE113513: Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, bilateralE113519: Type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema, unspecified eyeE113521: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, right eyeE113522: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, left eyeE113523: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, bilateralE113529: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment involving the macula, unspecified eyeE113531: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, right eyeE113532: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, left eyeE113533: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, bilateralE113539: Type 2 diabetes mellitus with proliferative diabetic retinopathy with traction retinal detachment not involving the macula, unspecified eyeE113541: Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, right eyeE113542: Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, left eyeE113543: Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, bilateralE113549: Type 2 diabetes mellitus with proliferative diabetic retinopathy with combined traction retinal detachment and rhegmatogenous retinal detachment, unspecified eyeE113551: Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, right eyeE113552: Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, left eyeE113553: Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, bilateralE113559: Type 2 diabetes mellitus with stable proliferative diabetic retinopathy, unspecified eyeE11359: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edemaE113591: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, right eyeE113592: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, left eyeE113593: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, bilateralE113599: Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema, unspecified eyeE1136: Type 2 diabetes mellitus with diabetic cataractE1137X1: Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, right eyeE1137X2: Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, left eyeE1137X3: Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, bilateralE1137X9: Type 2 diabetes mellitus with diabetic macular edema, resolved following treatment, unspecified eyeE1139: Type 2 diabetes mellitus with other diabetic ophthalmic complicationE1140: Type 2 diabetes mellitus with diabetic neuropathy, unspecifiedE1141: Type 2 diabetes mellitus with diabetic mononeuropathyE1142: Type 2 diabetes mellitus with diabetic polyneuropathyE1143: Type 2 diabetes mellitus with diabetic autonomic (poly)neuropathyE1144: Type 2 diabetes mellitus with diabetic amyotrophyE1149: Type 2 diabetes mellitus with other diabetic neurological complicationE1151: Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangreneE1152: Type 2 diabetes mellitus with diabetic peripheral angiopathy with gangreneE1159: Type 2 diabetes mellitus with other circulatory complicationsE11610: Type 2 diabetes mellitus with diabetic neuropathic arthropathyE11618: Type 2 diabetes mellitus with other diabetic arthropathyE11620: Type 2 diabetes mellitus with diabetic dermatitisE11621: Type 2 diabetes mellitus with foot ulcerE11622: Type 2 diabetes mellitus with other skin ulcerE11628: Type 2 diabetes mellitus with other skin complicationsE11630: Type 2 diabetes mellitus with periodontal diseaseE11638: Type 2 diabetes mellitus with other oral complicationsE1169: Type 2 diabetes mellitus with other specified complicationE118: Type 2 diabetes mellitus with unspecified complications PQI #14 Uncontrolled Diabetes Admission RateDischarges, for patients ages 18 years and older, with a principal ICD-10-CM diagnosis code for uncontrolled diabetes without mention of a short-term or long-term complicationE10649 Type 1 diabetes mellitus with hypoglycemia without comaE11649 Type 2 diabetes mellitus with hypoglycemia without comaE1065 Type 1 diabetes mellitus with hyperglycemiaE1165 Type 2 diabetes mellitus with hyperglycemia PQI #16 Lower Extremity Amputation aonb Patients with DiabetesDischarges, for patients ages 18 years and older, with any-listed ICD-10-PCS procedure codes for lower-extremity amputation0Y620ZZ: Detachment at Right Hindquarter, Open Approach0Y630ZZ: Detachment at Left Hindquarter, Open Approach0Y640ZZ: Detachment at Bilateral Hindquarter, Open Approach0Y670ZZ: Detachment at Right Femoral Region, Open Approach0Y680ZZ: Detachment at Left Femoral Region, Open Approach0Y6C0Z1: Detachment at Right Upper Leg, High, Open Approach0Y6C0Z2: Detachment at Right Upper Leg, Mid, Open Approach0Y6C0Z3: Detachment at Right Upper Leg, Low, Open Approach0Y6D0Z1: Detachment at Left Upper Leg, High, Open Approach0Y6D0Z2: Detachment at Left Upper Leg, Mid, Open Approach0Y6D0Z3: Detachment at Left Upper Leg, Low, Open Approach0Y6F0ZZ: Detachment at Right Knee Region, Open Approach0Y6G0ZZ: Detachment at Left Knee Region, Open Approach0Y6H0Z1: Detachment at Right Lower Leg, High, Open Approach0Y6H0Z2: Detachment at Right Lower Leg, Mid, Open Approach0Y6H0Z3: Detachment at Right Lower Leg, Low, Open Approach0Y6J0Z1: Detachment at Left Lower Leg, High, Open Approach0Y6J0Z2: Detachment at Left Lower Leg, Mid, Open Approach0Y6J0Z3: Detachment at Left Lower Leg, Low, Open Approach0Y6M0Z0: Detachment at Right Foot, Complete, Open Approach0Y6M0Z4: Detachment at Right Foot, Complete 1st Ray, Open Approach0Y6M0Z5: Detachment at Right Foot, Complete 2nd Ray, Open Approach0Y6M0Z6: Detachment at Right Foot, Complete 3rd Ray, Open Approach0Y6M0Z7: Detachment at Right Foot, Complete 4th Ray, Open Approach0Y6M0Z8: Detachment at Right Foot, Complete 5th Ray, Open Approach0Y6M0Z9: Detachment at Right Foot, Partial 1st Ray, Open Approach0Y6M0ZB: Detachment at Right Foot, Partial 2nd Ray, Open Approach0Y6M0ZC: Detachment at Right Foot, Partial 3rd Ray, Open Approach0Y6M0ZD: Detachment at Right Foot, Partial 4th Ray, Open Approach0Y6M0ZF: Detachment at Right Foot, Partial 5th Ray, Open Approach0Y6N0Z0: Detachment at Left Foot, Complete, Open Approach0Y6N0Z4: Detachment at Left Foot, Complete 1st Ray, Open Approach0Y6N0Z5: Detachment at Left Foot, Complete 2nd Ray, Open Approach0Y6N0Z6: Detachment at Left Foot, Complete 3rd Ray, Open Approach0Y6N0Z7: Detachment at Left Foot, Complete 4th Ray, Open Approach0Y6N0Z8: Detachment at Left Foot, Complete 5th Ray, Open Approach0Y6N0Z9: Detachment at Left Foot, Partial 1st Ray, Open Approach0Y6N0ZB: Detachment at Left Foot, Partial 2nd Ray, Open Approach0Y6N0ZC: Detachment at Left Foot, Partial 3rd Ray, Open Approach0Y6N0ZD: Detachment at Left Foot, Partial 4th Ray, Open Approach0Y6N0ZF: Detachment at Left Foot, Partial 5th Ray, Open ApproachAND any-listed ICD-10-CM diagnosis codes for diabetes.E1010, E1011, E1021, E1022, E1029, E10311, E10319, E10321, E103211, E103212, E103213, E103219, E10329, E103291, E103292, E103293, E103299, E10331, E103311, E103312, E103313, E103319, E10339, E103391, E103392, E103393, E103399, E10341, E103411, E103412, E103413, E103419, E10349, E103491, E103492, E103493, E103499, E10351, E103511, E103512, E103513, E103519, E103521, E103522, E103523, E103529, E103531, E103532, E103533, E103539, E103541, E103542, E103543, E103549, E103551, E103552, E103553, E103559, E10359, E103591, E103592, E103593, E103599, E1036, E1037X1, E1037X2, E1037X3, E1037X9, E1039, E1040, E1041, E1042, E1043, E1044, E1049, E1051, E1052, E1059, E10610, E10618, E10620, E10621, E10622, E10628, E10630, E10638, E10641, E10649, E1065, E1069, E108, E109, E1100, E1101, E1121, E1122, E1129, E11311, E11319, E11321, E113211, E113212, E113213, E113219, E11329, E113291, E113292, E113293, E113299, E11331, E113311, E113312, E113313, E113319, E11339, E113391, E113392, E113393, E113399, E11341, E113411, E113412, E113413, E113419, E11349, E113491, E113492, E113493, E113499, E11351, E113511, E113512, E113513, E113519, E113521, E113522, E113523, E113529, E113531, E113532, E113533, E113539, E113541, E113542, E113543, E113549, E113551, E113552, E113553, E113559, E11359, E113591, E113592, E113593, E113599, E1136, E1137X1, E1137X2, E1137X3, E1137X9, E1139, E1140, E1141, E1142, E1143, E1144, E1149, E1151, E1152, E1159, E11610, E11618, E11620, E11621, E11622, E11628, E11630, E11638, E11641, E11649, E1165, E1169, E118, E119, E1300, E1301, E1310, E1311, E1321, E1322, E1329, E13311, E13319, E13321, E133211, E133212, E133213, E133219, E13329, E133291, E133292, E133293, E133299, E13331, E133311, E133312, E133313, E133319, E13339, E133391, E133392, E133393, E133399, E13341, E133411, E133412, E133413, E133419, E13349, E133491, E133492, E133493, E133499, E13351, E133511, E133512, E133513, E133519, E133521, E133522, E133523, E133529, E133531, E133532, E133533, E133539, E133541, E133542, E133543, E133549, E133551, E133552, E133553, E133559, E13359, E133591, E133592, E133593, E133599, E1336, E1337X1, E1337X2, E1337X3, E1337X9, E1339, E1340, E1341, E1342, E1343, E1344, E1349, E1351, E1352, E1359, E13610, E13618, E13620, E13621, E13622, E13628, E13630, E13638, E13641, E13649, E1365, E1369, E138, E139, Numerator Exclusions (Performance Not Met)NOTE: Obstetric discharges should not be considered in the PQI rate, though the AHRQ QITM software does not explicitly exclude obstetric cases.]Exclude cases:? transfer from a hospital (different facility) (Appendix A)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix A)? transfer from another health care facility (Appendix A)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing)DSRIP Specific ModificationsSpecified that denominator is the DSRIP Attributed Target Population. Admissions should be limited to individuals from the DSRIP attributed target population.Additional InformationSee measure source for included and excluded valuesA1-508: Reduce Rate of Emergency Department visits for DiabetesMeasure Description:Rate of ED utilization for preventable Diabetes conditions or complicationsA1-508: Reduce Rate of Emergency Department visits for DiabetesDY7/DY8 Program IDA1-508Measure DetailsSteward: NANQF #: NASource: SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionTotal number of ED Visits with a primary or secondary diagnosis of diabetesNumerator Inclusions (Performance Met)Diabetes: 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. The denominator is the DSRIP attributed population, and the numerator should be limited to ED visits for individuals in the denominator.Bundle A2 Improved Chronic Disease Management: Heart DiseaseMeasure Bundle ObjectivesDevelop and implement chronic disease management interventions that are geared toward improving management of heart disease and comorbidities, improving health outcomes and quality of life, preventing disease complications, and reducing unnecessary acute and emergency care utilization.Target PopulationAdults in the DSRIP attributed population that are 18 or older at the beginning of the measurement period that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement periodANDwith a diagnosis of chronic heart disease (CHF, Angina, Hypertension, ASCVD, familial or pure hypercholesterolemia, any LDL-C result ≥ 190 mg/dL for any age, for individuals older than 40 any LCL-C result of 70–189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period). ___Exclude individuals enrolled in hospice during the measurement year. Related System ComponentsRequired Measures: Outpatient primary care, relevant outpatient specialty care where heart disease is managed MPT of 75 Requires ED, inpatientMPT below 75 requires ED and inpatient if availableNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesA2-103: 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.A2-103: Controlling High Blood PressureDY7/DY8 Program IDA2-103Measure DetailsSteward: NCQANQF #: 0018Source: CMS MIPS #236 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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"NOTE: Providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219, 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 chronic heart disease 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)"A2-210: 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 indicatedA2-210: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up DocumentedDY7/DY8 Program IDA2-210Measure DetailsSteward: CMSNQF #: NASource: CMS MIPS #317 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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"NOTE: Providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219, 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 chronic heart disease management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.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 ProviderRecommended 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 requiredB. 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 ProviderC. 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 ProviderD. 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)"A2-384: Risk Adjusted CHF 30-Day Readmission RateMeasure Description:Risk adjusted rate of hospital admissions (stays) for with a subsequent readmission for any reason within 30 days of discharge for CHF for patients 18 years of age and older.A readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year.A2-384: Risk Adjusted CHF 30-Day Readmission RateDY7/DY8 Program IDA2-384Measure DetailsSteward: NANQF #: NASource: NAData SourceClaimsRequired StatusOptional with additional points if selectedMeasure 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 DescriptionExpected (risk-adjusted) number of readmissions for all-causes during the measurement year.The Expected number reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected number is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.Denominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionObserved (Actual) number of readmissions within 30 days following an Index Admission during the measurement yearNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSee risk adjusting guidance for additional informationA2-404: Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseMeasure Description:Percentage of the following patients—all considered at high risk of cardiovascular events—who were prescribed or were on statin therapy during the measurement period:? Adults aged ≥ 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR? Adults aged ≥21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR? Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL THERE ARE THREE REPORTING CRITERIA FOR THIS MEASURE**:1) Patients aged ≥ 21 years at the beginning of the measurement period with clinical ASCVD diagnosisOR2) Patients aged ≥ 21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemiaOR3) Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70–189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period**All patients who meet one or more of the following criteria indicated above would be considered at high risk for cardiovascular events under the ACC/AHA guidelines. When reporting this measure determine if the patient meets denominator eligibility in order of each risk category.A2-404: Statin Therapy for the Prevention and Treatment of Cardiovascular DiseaseDY7/DY8 Program IDA2-404Measure DetailsSteward: AMANQF #: NASource: CMS MIPS #438 (Claims/Registry)eMeasure SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 DescriptionCRITERIA 1: Patients aged ≥21 years at the beginning of the measurement period with clinical ASCVD diagnosis Definitions:Clinical Atherosclerotic Cardiovascular Disease (ASCVD) includes:? Acute Coronary Syndromes? History of Myocardial Infarction? Stable or Unstable Angina? Coronary or other Arterial Revascularization? Stroke or Transient Ischemic Attack (TIA)? Peripheral Arterial Disease of Atherosclerotic Origin Lipoprotein Density Cholesterol (LDL-C) result - A fasting or direct LDL-C laboratory test performed and test result documented in the medical record CRITERIA 2: Patients aged ≥21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C ≥ 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemiaDefinition:Lipoprotein Density Cholesterol (LDL-C) result - A fasting or direct LDL-C laboratory test performed and test result documented in the medical record CRITERIA 3: Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with a LDL-C result of 70–189 mg/dL recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period Lipoprotein Density Cholesterol (LDL-C) result - A fasting or direct LDL-C laboratory test performed and test result documented in the medical recordDenominator InclusionsCLAIMS/REGISTRYCRITERIA 1: Patients aged ≥ 21 years at the beginning of the measurement periodANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402, 99403, 99404, G0438, G0439WITHOUTTelehealth Modifier: GQ, GTANDPreviously diagnosed or have an active diagnosis of Clinical ASCVD: G9662 CRITERIA 2: Patient aged ≥21 years at the beginning of the measurement periodANDPatient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212,99213, 99214, 99215, 99241, 99242, 99243, 99244*, 99245, 99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402, 99403, 99404, G0438, G0439WITHOUTTelehealth Modifier: GQ, GTANDAny fasting or direct LDL-C laboratory test result ≥ 190 mg/dL: G9663ORHistory of or active diagnosis of familial or pure hypercholesterolemia: G9782 CRITERIA 3:Patients aged 40 through 75 years at the beginning of the measurement periodANType 1 or Type 2 diabetes diagnosis (ICD-10-CM): E10.10, E10.11, E10.21, E10.22, E10.29, E10.311, E10.319, E10.321, E10.3211, E10.3212, E10.3213, E10.3219, E10.329, E10.3291, E10.3292, E10.3293, E10.3299, E10.331, E10.3311, E10.3312, E10.3313, E10.3319, E10.339, E10.3391, E10.3392, E10.3393, E10.3399, E10.341, E10.3411, E10.3412, E10.3413, E10.3419, E10.349, E10.3491, E10.3492, E10.3493, E10.3499, E10.351, 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, E10.359, 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, E11.321, E11.3211, E11.3212, E11.3213, E11.3219, E11.329, E11.3291, E11.3292, E11.3293, E11.3299, E11.331, E11.3311, E11.3312, E11.3313, E11.3319, E11.339, E11.3391, E11.3392, E11.3393, E11.3399, E11.341, E11.3411, E11.3412, E11.3413, E11.3419, E11.349, E11.3491, E11.3492, E11.3493, E11.3499, E11.351, 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, E11.359, E11.3591, E11.3592, E11.3593, E11.3599, E11.36, 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, E13.321, E13.3211, E13.3212, E13.3213, E13.3219, E13.329, E13.3291, E13.3292, E13.3293, E13.3299 E13.331, E13.3311, E13.3312, E13.3313, E13.3319, E13.339, E13.3391, E13.3392, E13.3393, E13.3399, E13.341, E13.3411, E13.3412, E13.3413, E13.3419, E13.349, E13.3491, E13.3492, E13.3493, E13.3499, E13.351, 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, E13.359, 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 the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212,99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99401*, 99402*, 99403*, 99404*, G0438, G0439WITHOUTTelehealth Modifier: GQ, GTANDThe highest fasting or direct LDL-C laboratory test result of 70 –189 mg/dL in the measurement period or two years prior to the beginning of the measurement period: G9666 E.H.R.Population Criteria 1:Initial Population = AND: $Encounters_For_Statin_Therapy AND: Age >= 21 year(s) at: "Measurement Period"Denominator = AND: Initial Population AND: $History_of_Clinical_ASCVD Population Criteria 2:Initial Population = AND: $Encounters_For_Statin_Therapy AND: Age >= 21 year(s) at: "Measurement Period"Denominator = AND: Initial Population AND NOT: $History_of_Clinical_ASCVD AND: - OR: "Laboratory Test, Performed: LDL Test (result >= 190 mg/dL)" starts before end of "Measurement Period" - OR: "Diagnosis: Hypercholesterolemia" starts before end of "Measurement Period" Population Criteria 3:Initial Population = AND: $Encounters_For_Statin_Therapy AND: Age >= 21 year(s) at: "Measurement Period"Denominator = AND: Initial Population AND: "Diagnosis: Diabetes" starts before end of "Measurement Period" AND NOT: $History_of_Clinical_ASCVD AND: Age >= 40 year(s) at: "Measurement Period" AND: Age <= 75 year(s) at: "Measurement Period" AND NOT: "Laboratory Test, Performed: LDL Test (result >= 190 mg/dL)" starts before end of "Measurement Period" AND NOT: "Diagnosis: Hypercholesterolemia" starts before end of "Measurement Period" # Includes tests performed in the two calendar years prior to the start of the measurement period AND: "Laboratory Test, Performed: LDL Test" satisfies all: - (result < 190 mg/dL) - (result >= 70 mg/dL) - <= 3 year(s) starts before end of "Measurement Period" ***(SEE DSRIP SPECIFIC MODIFICATION)NOTE: Providers should limit office visit/E&M CPT codes 99201 - 99205 and 99211 - 99219, 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 chronic heart disease management. Encounters may be limited by clinic, place of service, or physician but not by visit specific services.Denominator ExclusionsCLAIMS/REGISTRYCRITERIA 1:Patients who have a diagnosis of pregnancy: G9778ORPatients who are breastfeeding: G9779ORPatients who have a diagnosis of rhabdomyolysis: G9780ORDocumentation of medical reason(s) for not currently being a statin therapy user or receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, and patients with end stage renal disease (ESRD) (G9781) CRITERIA 2: Patients who have a diagnosis of pregnancy: G9778ORPatients who are breastfeeding: G9779ORPatients who have a diagnosis of rhabdomyolysis: G9780ORDocumentation of medical reason(s) for not currently being a statin therapy user or receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, and patients with end stage renal disease (ESRD) (G9781) CRITERIA 3:Patients who have a diagnosis of pregnancy: G9778ORPatients who are breastfeeding: G9779ORPatients who have a diagnosis of rhabdomyolysis: G9780ORDocumentation of medical reason(s) for not currently being a statin therapy user or receive an order (prescription) for statin therapy (e.g., patient with adverse effect, allergy or intolerance to statin medication therapy, patients who are receiving palliative care, patients with active liver disease or hepatic disease or insufficiency, patients with end stage renal disease (ESRD) (G9781)ORDocumentation of patients with diabetes who have a most recent fasting or direct LDL- C laboratory test result < 70 mg/dL and are not taking statin therapy (G9783) EHRPopulation Criteria 1: Denominator Exclusions: OR: $Statin_Use_ExclusionDenominator Exceptions: OR: $Statin_Use_Exception Population Criteria 2:Denominator Exclusions: OR: $Statin_Use_ExclusionDenominator Exceptions: OR: $Statin_Use_Exception Population Criteria 3:Denominator Exclusions = OR: $Statin_Use_ExclusionDenominator Exceptions = OR: $Statin_Use_Exception # Includes tests performed in the two calendar years prior to the start of the measurement period OR: "Laboratory Test, Performed: LDL Test" satisfies all: - Most Recent: (result) <= 2 year(s) starts before end of "Measurement Period" - (result < 70 mg/dL)Numerator DescriptionCLAIMS/REGISTRYPatients who are actively using or who receive an order (prescription) for statin therapy at any point during the measurement period Definitions:Statin therapy - Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.Sample list of statin medications (list is NOT inclusive of all agents) is included in the clinical recommendationsActive Liver or Hepatic Disease or Insufficiency – The following codes are included in the Denominator Exception (G9667) to define liver disease: B15.0, B15.9, B16.0, B16.1, B16.2, B16.9, B18.0, B18.1, B19.10, B19.11, B17.0, B17.2, B17.8, B17.10, B17.11, B18.2, B18.8, B18.9, B19.0, B19.20, B19.21, K70.0, K70.9, K70.30, K70.31, K70.40, K70.41, K71.3, K71.4, K71.9, K71.10, K71.11, K71.50, K71.51, K72.00, K72.01, K72.10, K72.11, K72.90, K72.91, K73.0, K73.2, K73.8, K73.9, K74.0, K74.1, K74.2, K74.3, K74.4, K74.5, K74.60, K74.69, K75.4, K76.0, K76.2, K76.3, K76.7, K76.9, K76.89, O98.419, Z22.51 NUMERATOR NOTE: In order to meet the measure, current statin therapy use must be documented in the patient’s current medication list or ordered during the measurement period. Only statin therapy meets the measure Numerator criteria (NOT other cholesterol lowering medications). Prescription or order does NOT need to be linked to an encounter or visit; may be called to the pharmacy. Statin medication “samples” provided to patients can be documented as “current statin therapy” if documented in the medication list in health/medical record. Patients who meet the denominator criteria for inclusion but are not prescribed or using statin therapy will NOT meet performance for this measure. Adherence to statin therapy is not calculated in this measure.Numerator Inclusions (Performance Met)CLAIMS/REGISTRYPatients who are currently statin therapy users or received an order (prescription) for statin therapy (G9664) E.H.R.AND: OR: Union of: - "Medication, Order: Low intensity statin therapy" - "Medication, Order: Moderate intensity statin therapy" - "Medication, Order: High intensity statin therapy" - during "Measurement Period" OR: - AND: Occurrence A of $AnyStatinActiveSBEMP = AND NOT: Occurrence A of $AnyStatinActiveSBEMP ends before end of "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRYPatients who are not currently statin therapy users or did not receive an order (prescription) for statin therapy (G9665) E.H.R.NoneDSRIP Specific ModificationsRemoved Medicare specific clarifications regarding non-covered services under Medicare Part B. Combined numerator description and details for Criteria 1 - 3 as numerator description and details are identical for all three criteria and for DSRIP purposes***HHSC modified the Denominator Inclusions for Population Criteria 3 to match updated measure specifications from the measure steward to address an error. Prior specifications for Population Criteria 3 stated "<= 2 year(s) starts before end of ‘Measurement Period’" but corrected measure specifications state "LDL 70 to 189 During or 2 Years Before Start of Measurement Period". HHSC has updated the measure specifications to "<= 3 year(s) starts before end of ‘Measurement Period’" to correct the error and align with measure description.Additional InformationE.H.R.Data Criteria (QDM Variables):? $History_of_Clinical_ASCVD = o Union of: - "Procedure, Performed: PCI" - "Diagnosis: Myocardial Infarction" -"Diagnosis: Cerebrovascular disease, Stroke, TIA" - "Procedure, Performed: CABG Surgeries" - "Diagnosis: Atherosclerosis and Peripheral Arterial Disease" - "Procedure, Performed: Carotid Intervention" -"Diagnosis: Ischemic heart disease or coronary occlusion, rupture, or thrombosis" - "Diagnosis: Stable and Unstable Angina" - starts before end of "Measurement Period"? $Statin_Use_Exclusion = o Union of: - "Diagnosis: Pregnancy Dx" - "Diagnosis: Breastfeeding" - "Diagnosis: Rhabdomyolysis" - overlaps "Measurement Period"? $Encounters_For_Statin_Therapy = o Union of: - "Encounter, Performed: Office Visit" -"Encounter, Performed: Outpatient Consultation" - "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" - "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" - "Encounter, Performed: Preventive Care Services-Individual Counseling" -"Encounter, Performed: Preventive Care Services - Other" -"Encounter, Performed: Annual Wellness Visit" - "Encounter, Performed: Outpatient Encounters for Preventive Care" -during "Measurement Period"? $AnyStatinActiveSBEMP = o Union of: - "Medication, Active: Low intensity statin therapy" - "Medication, Active: Moderate intensity statin therapy" - "Medication, Active: High intensity statin therapy" - starts before end of "Measurement Period"? $Statin_Use_Exception = o Union of:- "Intervention, Performed: Palliative Care" - "Diagnosis: End Stage Renal Disease" - "Diagnosis: Hepatitis A" - "Diagnosis: Hepatitis B" - "Diagnosis: Liver Disease" - "Medication, Adverse Effects: Statin Allergen" - "Medication, Allergy: Statin Allergen" - "Medication, Intolerance: Statin Allergen" - overlaps "Measurement Period" Data Criteria (QDM Data Elements):? "Diagnosis: Atherosclerosis and Peripheral Arterial Disease" using "Atherosclerosis and Peripheral Arterial Disease Grouping Value Set (2.16.840.1.113762.1.4.1047.21)"? "Diagnosis: Breastfeeding" using "Breastfeeding Grouping Value Set (2.16.840.1.113762.1.4.1047.73)"? "Diagnosis: Cerebrovascular disease, Stroke, TIA" using "Cerebrovascular disease, Stroke, TIA Grouping Value Set (2.16.840.1.113762.1.4.1047.44)"? "Diagnosis: Diabetes" using "Diabetes Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1001)"? "Diagnosis: End Stage Renal Disease" using "End Stage Renal Disease Grouping Value Set (2.16.840.1.113883.3.526.3.353)"? "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 (2.16.840.1.113883.3.67.1.101.1.269)"? "Diagnosis: Hypercholesterolemia" using "Hypercholesterolemia Grouping Value Set (2.16.840.1.113762.1.4.1047.100)"? "Diagnosis: Ischemic heart disease or coronary occlusion, rupture, or thrombosis" using "Ischemic heart disease or coronary occlusion, rupture, or thrombosis Grouping Value Set (2.16.840.1.113762.1.4.1047.46)"? "Diagnosis: Liver Disease" using "Liver Disease Grouping Value Set (2.16.840.1.113762.1.4.1047.42)"? "Diagnosis: Myocardial Infarction" using "Myocardial Infarction Grouping Value Set (2.16.840.1.113883.3.526.3.403)"? "Diagnosis: Pregnancy Dx" using "Pregnancy Dx Grouping Value Set (2.16.840.1.113883.3.600.1.1623)"? "Diagnosis: Rhabdomyolysis" using "Rhabdomyolysis Grouping Value Set (2.16.840.1.113762.1.4.1047.102)"? "Diagnosis: Stable and Unstable Angina" using "Stable and Unstable Angina Grouping Value Set (2.16.840.1.113762.1.4.1047.47)"? "Encounter, Performed: Annual Wellness Visit" using "Annual Wellness Visit HCPCS Value Set (2.16.840.1.113883.3.526.2.1363)"? "Encounter, Performed: Office Visit" using "Office Visit CPT Value Set (2.16.840.1.113883.3.464.1003.101.11.1005)"? "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation CPT Value Set (2.16.840.1.113883.3.464.1003.101.11.1040)"? "Encounter, Performed: Outpatient Encounters for Preventive Care" using "Outpatient Encounters for Preventive Care SNOMEDCT Value Set (2.16.840.1.113762.1.4.1047.9)"? "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" using "Preventive Care Services - Established Office Visit, 18 and Up CPT Value Set (2.16.840.1.113883.3.464.1003.101.11.1125)"? "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 CPT Value Set (2.16.840.1.113883.3.464.1003.101.11.1115)"? "Intervention, Performed: Palliative Care" using "Palliative Care Grouping Value Set (2.16.840.1.113883.3.600.1.1579)"? "Laboratory Test, Performed: LDL Test" using "LDL Test LOINC Value Set (2.16.840.1.113883.3.464.1003.198.11.1029)"? "Medication, Active: High intensity statin therapy" using "High intensity statin therapy RXNORM Value Set (2.16.840.1.113762.1.4.1047.97)"? "Medication, Active: Low intensity statin therapy" using "Low intensity statin therapy RXNORM Value Set (2.16.840.1.113762.1.4.1047.107)"? "Medication, Active: Moderate intensity statin therapy" using "Moderate intensity statin therapy RXNORM Value Set (2.16.840.1.113762.1.4.1047.98)"? "Medication, Adverse Effects: Statin Allergen" using "Statin Allergen RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.423)"? "Medication, Allergy: Statin Allergen" using "Statin Allergen RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.423)"? "Medication, Intolerance: Statin Allergen" using "Statin Allergen RXNORM Value Set (2.16.840.1.113883.3.117.1.7.1.423)"? "Medication, Order: High intensity statin therapy" using "High intensity statin therapy RXNORM Value Set (2.16.840.1.113762.1.4.1047.97)"? "Medication, Order: Low intensity statin therapy" using "Low intensity statin therapy RXNORM Value Set (2.16.840.1.113762.1.4.1047.107)"? "Medication, Order: Moderate intensity statin therapy" using "Moderate intensity statin therapy RXNORM Value Set (2.16.840.1.113762.1.4.1047.98)"? "Procedure, Performed: CABG Surgeries" using "CABG Surgeries Grouping Value Set (2.16.840.1.113883.3.666.5.694)"? "Procedure, Performed: Carotid Intervention" using "Carotid Intervention Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.204)"? "Procedure, Performed: PCI" using "PCI Grouping Value Set (2.16.840.1.113762.1.4.1045.67)"A2-501: PQI 08 Heart Failure Admission Rate (Adult)Measure Description:Admissions with a principal diagnosis of heart failure per 100,000 population, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions.A2-501: PQI 08 Heart Failure Admission Rate (Adult)DY7/DY8 Program IDA2-501Measure DetailsSteward: AHRQNQF #: 0277Source: AHRQ: SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionDischarges, for patients ages 18 years and older, with a principal ICD-10-CM diagnosis code for heart failureNumerator Inclusions (Performance Met)Heart failure diagnosis codes: (MRTCHFD)I0981 Rheumatic heart failureI5030 Unspecified diastolic (congestive) heart failureI110 Hypertensive heart disease with heart failureI5031 Acute diastolic (congestive) heart failureI130 Hypertensive heart and chronic kidney disease with heart failure and stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney diseaseI5032 Chronic diastolic (congestive) heart failureI132 Hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, or end stage renal diseaseI5033 Acute on chronic diastolic (congestive) heart failureI501 Left ventricular failureI5040 Unspecified combined systolic (congestive) and diastolic (congestive) heart failureI5020 Unspecified systolic (congestive) heart failureI5041 Acute combined systolic (congestive) and diastolic (congestive) heart failureI5021 Acute systolic (congestive) heart failureI5042 Chronic combined systolic (congestive) and diastolic (congestive) heart failureI5022 Chronic systolic (congestive) heart failureI5043 Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failureI5023 Acute on chronic systolic (congestive) heart failureI509 Heart failure, unspecifiedNumerator Exclusions (Performance Not Met)NOTE: Obstetric discharges should not be considered in the PQI rate, though the AHRQ QITM software does not explicitly exclude obstetric cases.Exclude cases:? with any listed ICD-10-PCS procedure codes for cardiac procedure (ACSCARP*)? transfer from a hospital (different facility) (Appendix A)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix A)? transfer from another health care facility (Appendix A)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing)DSRIP Specific ModificationsSpecified that denominator is the DSRIP Attributed Target Population. Admissions should be limited to individuals from the DSRIP attributed target population.Additional InformationSee measure source for included and excluded valuesA2-509: Reduce Rate of Emergency Department visits for CHF, Angina, and HypertensionMeasure Description:Rate of ED utilization for CHF, Angina, and HypertensionA2-509: Reduce Rate of Emergency Department visits for CHF, Angina, and HypertensionDY7/DY8 Program IDA2-509Measure DetailsSteward: NANQF #: NASource: SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionTotal number of ED Visits with a primary or secondary diagnosis of selected conditionNumerator Inclusions (Performance Met)Heart failure and pulmonary edema: I50, I110, J810, Exclude cases with a surgical procedure starting with 02 Hypertension: I10, I119, I16 Exclude cases with a surgical procedure starting with 02 Angina: I20, I240, I248, I249, Exclude cases with a surgical procedure starting with 0 or 1Numerator 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. The denominator is the DSRIP attributed population, and the numerator should be limited to ED visits for individuals in the denominator.Bundle B1 Care Transitions & Hospital ReadmissionsMeasure Bundle ObjectivesImplement improvements in care transitions and coordination of care from inpatient to outpatient, post‐acute care, and home care settings in order to improve health outcomes, and prevent increased health care costs and hospital readmissions.Target PopulationIndividuals admitted to a hospital setting (including observation status, inpatient, and ED discharges)Related System ComponentsHospitalNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNoMeasures Hospital BasedServicesYesB1-124: Medication Reconciliation Post-DischargeMeasure Description:The percentage of discharges for patients 18 years of age and older for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record by a prescribing practitioner, clinical pharmacist or registered nurse.B1-124: Medication Reconciliation Post-DischargeDY7/DY8 Program IDB1-124Measure DetailsSteward: NCQANQF #: 0097Source: CMS MIPS #46 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll discharges from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) for patients18 years of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care.Denominator InclusionsAll Patients 18 years of age and older ANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 90845, 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, 99495, 99496, G0402, G0438, G0439 AND Patient discharged from an inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) within the last 30 daysDenominator ExclusionsPatient had hospice services any time during the measurement period: G9691Numerator DescriptionMedication reconciliation conducted by a prescribing practitioner, clinical pharmacists or registered nurse on or within 30 days of discharge. Definition: Medication Reconciliation – A type of review in which the discharge medications are reconciled withthe most recent medication list in the outpatient medical record. Documentation in the outpatient medical record must include evidence of medication reconciliation and the date on which it was performed. Any of the following evidence meets criteria: (1) Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds atdischarge, discontinue all discharge meds), (2) Documentation of the patient’s current medications with a notation that the discharge medications were reviewed, (3) Documentation that the provider “reconciled the current and discharge meds,” (4) Documentation of a current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service, (5) Notation that no medications were prescribed or ordered upon discharge NUMERATOR NOTE: Medication reconciliation should be completed and documented on or within 30 days of discharge. If the patient has an eligible discharge but medication reconciliation is not performed and documented within 30 days, report 1111F with 8P.Numerator Inclusions (Performance Met)Discharge medications reconciled with the current medication list in outpatient medical record (1111F)Numerator Exclusions (Performance Not Met)Discharge medications not reconciled with the current medication list in outpatient medical record, reason not otherwise specified (1111F with 8P)DSRIP Specific ModificationsNoneAdditional InformationNoneB1-141: Risk Adjusted All-Cause 30-Day Readmission for Targeted Conditions: heart failure hospitalization, coronary artery bypass graft (CABG) surgery, CHF, Diabetes, AMI, Stroke, COPD, Behavioral Health, Substance UseMeasure Description:Risk adjusted rate of hospital admissions (stays) for with a subsequent readmission for any reason within 30 days of discharge for a targeted condition for patients 18 years of age and older.A readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year. NOTE: Providers may select one or more targeted conditions. Targeted conditions may not duplicate a readmissions measure selected as part of another measure bundle.B1-141: Risk Adjusted All-Cause 30-Day Readmission for Targeted Conditions: heart failure hospitalization, coronary artery bypass graft (CABG) surgery, CHF, Diabetes, AMI, Stroke, COPD, Behavioral Health, Substance UseDY7/DY8 Program IDB1-141Measure DetailsSteward: NANQF #: NASource: NAData SourceClaimsRequired StatusRequiredMeasure 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 DescriptionExpected (risk-adjusted) number of readmissions for all-causes within 30 days following an Index Admission for the selected targeted condition during the measurement year.The Expected number reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected number is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.Denominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionObserved (Actual) number of readmissions for all-causes within 30 days following an Index Admission for the selected targeted condition during the measurement yearNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSee risk adjusting guidance for additional informationProviders will report one actual and one expected rate for representing all selected targeted conditions (for example, one rate that is the actual and expected readmissions total following admission for CHF, AMI, and CABG surgery)B1-217: Risk Adjusted All-Cause 30-Day ReadmissionMeasure Description:Risk adjusted rate of hospital admissions (stays) for with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older.A readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year.B1-217: Risk Adjusted All-Cause 30-Day ReadmissionDY7/DY8 Program IDB1-217Measure DetailsSteward: NANQF #: NASource: NAData SourceClaims, otherRequired StatusRequiredMeasure 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 DescriptionExpected (risk-adjusted) number of readmissions for all-causes during the measurement year.The Expected number reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected number is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.Denominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionObserved (Actual) number of readmissions within 30 days following an Index Admission during the measurement yearNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSee risk adjusting guidance for additional informationB1-252: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges)Measure Description:Percentage of patients, regardless of age, discharged from an emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of the specified elementsB1-252: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges)DY7/DY8 Program IDB1-252Measure DetailsSteward: AMA-PCPINQF #: 0649Source: SourceClaimsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll patients, regardless of age, discharged from an emergency department (ED) to ambulatory care (home/self care) or home health careDenominator InclusionsIdentify patients discharged from emergency department to home or self care using the following:UB-04 (Form Locator 42 - Revenue Code): ? 0450 (Emergency Room)ANDUB-04 (Form Locator 17 - Discharge Status): ? 01 (Discharged to home care or self care (routine discharge)) ? 06 (Discharged/transferred to home under care of organized home health service org. in anticipation of covered skilled care) ? 21 (Discharged/transferred to court/law enforcement)(Note: Only the above codes from UB-04 Form Locator 17 - Discharge Status should be included in the eligible population.)Denominator ExclusionsExclusions: UB-04 (Form Locator 17 - Discharge Status):? 07 (Left against medical advice or discontinued care)*? 20 (Expired)? 40 (Expired at home)? 41 (Expired in a medical facility (e.g. hospital, SNF, ICF, or free standing hospice))? 42 (Expired-place unknown) Exceptions: Documentation is required for the following patients who are excepted from the measure:? Patients who declined receipt of transition record.? Patients for whom providing the information contained in the transition record would be prohibited by state or federal law.Numerator DescriptionPatients or their caregiver(s) who received a transition record at the time of emergency department (ED) discharge including, at a minimum, all of the following elements:?Summary of major procedures and tests performed during ED visit, AND?Principal clinical diagnosis at discharge which may include the presenting chief complaint, AND?Patient instructions, AND?Plan for follow-up care (OR statement that none required), including primary physician, other health care professional, or site designated for follow-up care, AND?List of new medications and changes to continued medications that patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for eachNumerator Inclusions (Performance Met)Numerator Elements to be identified through medical record abstraction.Sample Data Collection Tool available at (Measure #4)Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationMeasure is Measure #4 of the American Medical Association-convened Physician Consortium for Performance Improvement? American Board of Internal Medicine Foundation American College of Physicians Society of Hospital Medicine Care Transitions Performance Measurement Set for Inpatient Discharges & Emergency Department Discharges. Numerator Element Definitions:a. Transition record (for ED discharges): a core, standardized set of data elements related to patient’s diagnosis, treatment, and care plan that is discussed with, provided to and accepted by the patient in written, printed, or electronic format. Electronic format may be provided only if acceptable to patient.b. Summary of any major tests and procedures performed during the emergency department encounter must be included in the transition record, but it is not the intention of the measure that a complete order set is provided to all patients. The types of procedures and tests included should be defined by each emergency department prior to measure implementation and may include fracture management, wound repair, incision and drainage (I & D), foreign body removal, joint reduction, joint aspiration, chest tube placement, emergency endotracheal intubation, central line placement, or lumbar punctures. Tests may include lab tests, scans, or x-rays that were performed. Major tests that have results pending should be included, since they were performed during the encounter and will require follow up after the patient leaves the ED.c. Primary physician or other health care professional designated for follow-up care: may be primary care physician (PCP), medical specialist, or other physician or health care professional. If no physician, other health care professional, or site designated or available, patient may be provided with information on alternatives for obtaining follow-up care needed, which may include a list of community health services/other resources.B1-253: Transition Record with Specified Elements Received by Discharged Patients (Discharges from Inpatient Facility)Measure Description:Percentage of patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elementsB1-253: Transition Record with Specified Elements Received by Discharged Patients (Discharges from Inpatient Facility)DY7/DY8 Program IDB1-253Measure DetailsSteward: AMA-PCPINQF #: NASource: SourceClaimsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll patients, regardless of age, discharged from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self care or any other site of care.Denominator InclusionsIdentify patients discharged from inpatient facility using the following:UB-04 (Form Locator 04 - Type of Bill):? 0111 (Hospital Inpatient (Including Medicare Part A), Admit through Discharge Claim)? 0114 (Hospital Inpatient (Including Medicare Part A), Interim - Last Claim)? 0121 (Hospital Inpatient (Medicare Part B only), Admit through Discharge Claim)? 0124 (Hospital Inpatient (Medicare Part B only), Interim - Last Claim)? 0181 (Hospital - Swing Beds, Admit through Discharge Claim)? 0184 (Hospital - Swing Beds, Interim - Last Claim)? 0211 (Skilled Nursing-Inpatient (Including Medicare Part A), Admit through Discharge Claim)? 0214 (Skilled Nursing-Inpatient (Including Medicare Part A), Interim - Last Claim)? 0221 (Skilled Nursing-Inpatient (Medicare Part B only), Admit through Discharge Claim)? 0224 (Skilled Nursing- Inpatient (Medicare Part B only), Interim - Last Claim)? 0281 (Skilled Nursing-Swing Beds, Admit through Discharge Claim)? 0284 (Skilled Nursing-Swing Beds, Interim - Last Claim)ANDDischarge Status (Form Locator 17)? 01 (Discharged to home or self care (routine discharge)? 02 (Discharged/transferred to a short term general hospital for inpatient care)? 03 (Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care)? 04 (Discharged/transferred to a facility that provides custodial or supportive care)? 05 (Discharged/transferred to a designated cancer center or children’s hospital)? 06 (Discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care)? 21 (Discharged/transferred to court/law enforcement)? 43 (Discharged/transferred to a federal health care facility)? 50 (Hospice – home)? 51 (Hospice - medical facility (certified) providing hospice level of care)? 61 (Discharged/transferred to hospital-based Medicare approved swing bed)? 62 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital)? 63 (Discharged/transferred to a Medicare certified long term care hospital (LTCH))? 64 (Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare)? 65 (Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital)? 66 (Discharged/transferred to a Critical Access Hospital (CAH))? 69 (Discharged/transferred to a designated disaster alternative care site)? 70 (Discharged/transferred to another type of health care institution not defined elsewhere in this code list)? 81 (Discharged to home or self care with a planned acute care hospital inpatient readmission)? 82 (Discharged/transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission)? 83 (Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission)? 84 (Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission)? 85 (Discharged/transferred to a designated cancer center or children’s hospital with a planned acute care hospital inpatient readmission)? 86 (Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission)? 87 (Discharged/transferred to court/law enforcement with a planned acute care hospital inpatient readmission)? 88 (Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission? 89 (Discharged/transferred to a hospital-based Medicare approved swing bed with a planned acute care hospital inpatient readmission)? 90 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission)? 91 (Discharged/transferred to a Medicare certified long term care hospital (LTCH) with a planned acute care hospital inpatient readmission)? 92 (Discharged/transferred to nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission)? 93 (Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital with a planned acute care hospital inpatient readmission)? 94 (Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission)? 95 (Discharged/transferred to another type of health care institution not defined elsewhere in this code list with a planned acute care hospital inpatient readmission)ORUB-04 (Form Locator 04 - Type of Bill):? 0131 (Hospital Outpatient, Admit through Discharge Claim)? 0134 (Hospital Outpatient, Interim - Last Claim)ANDUB-04 (Form Locator 42 - Revenue Code):? 0762 (Hospital Observation)? 0490 (Ambulatory Surgery)? 0499 (Other Ambulatory Surgery)ANDDischarge Status (Form Locator 17)? 01 (Discharged to home or self care (routine discharge)? 02 (Discharged/transferred to a short term general hospital for inpatient care)? 03 (Discharged/transferred to skilled nursing facility (SNF) with Medicare certification in anticipation of skilled care)? 04 (Discharged/transferred to a facility that provides custodial or supportive care)? 05 (Discharged/transferred to a designated cancer center or children’s hospital? 06 (Discharged/transferred to home under care of an organized home health service organization in anticipation of covered skilled care)? 21 (Discharged/transferred to court/law enforcement)? 43 (Discharged/transferred to a federal health care facility)? 50 (Hospice – home)? 51 (Hospice - medical facility (certified) providing hospice level of care)? 61 (Discharged/transferred to hospital-based Medicare approved swing bed)? 62 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital)? 63 (Discharged/transferred to a Medicare certified long term care hospital (LTCH))? 64 (Discharged/transferred to a nursing facility certified under Medicaid but not certified under Medicare)? 65 (Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital)? 66 (Discharged/transferred to a Critical Access Hospital (CAH))? 69 (Discharged/transferred to a designated disaster alternative care site)? 70 (Discharged/transferred to another type of health care institution not defined elsewhere in this code list)? 81 (Discharged to home or self-care with a planned acute care hospital inpatient readmission)? 82 (Discharged/transferred to a short term general hospital for inpatient care with a planned acute care hospital inpatient readmission)? 83 (Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission)? 84 (Discharged/transferred to a facility that provides custodial or supportive care with a planned acute care hospital inpatient readmission)? 85 (Discharged/transferred to a designated cancer center or children’s hospital with a planned acute care hospital inpatient readmission)? 86 (Discharged/transferred to home under care of organized home health service organization with a planned acute care hospital inpatient readmission)? 87 (Discharged/transferred to court/law enforcement with a planned acute care hospital inpatient readmission)? 88 (Discharged/transferred to a federal health care facility with a planned acute care hospital inpatient readmission? 89 (Discharged/transferred to a hospital-based Medicare approved swing bed with a planned acute care hospital inpatient readmission)? 90 (Discharged/transferred to an inpatient rehabilitation facility (IRF) including rehabilitation distinct part units of a hospital with a planned acute care hospital inpatient readmission)? 91 (Discharged/transferred to a Medicare certified long term care hospital (LTCH) with a planned acute care hospital inpatient readmission)? 92 (Discharged/transferred to nursing facility certified under Medicaid but not certified under Medicare with a planned acute care hospital inpatient readmission)? 93 (Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital with a planned acute care hospital inpatient readmission)? 94 (Discharged/transferred to a critical access hospital (CAH) with a planned acute care hospital inpatient readmission)? 95 (Discharged/transferred to another type of health care institution not defined elsewhere in this code list with a planned acute care hospital inpatient readmission)Denominator ExclusionsUB-04 (Form Locator 17 - Discharge Status):? 07 (Left against medical advice or discontinued care)? 20 (Expired)? 40 (Expired at home)? 41 (Expired in a medical facility (e.g. hospital, SNF, ICF, or free standing hospice))? 42 (Expired-place unknown)Numerator DescriptionPatients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements: 1. Inpatient Care:? Reason for inpatient admission, AND? Major procedures and tests performed during inpatient stay and summary of results, AND? Principal diagnosis at discharge2. Post-Discharge/ Patient Self-Management:? Current medication list, AND? Studies pending at discharge (eg, laboratory, radiological), AND? Patient instructions3. Advance Care Plan:? Advance directives or surrogate decision maker documented OR ? Documented reason for not providing advance care plan4. Contact Information/Plan for Follow-up Care? 24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND? Contact information for obtaining results of studies pending at discharge, AND? Plan for follow-up care, AND? Primary physician, other health care professional, or site designated for follow-up careNumerator Inclusions (Performance Met)Numerator Elements to be identified through medical record abstraction.Sample Data Collection Tool available at (Measure #2)Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationMeasure is Measure #2 of the American Medical Association-convened Physician Consortium for Performance Improvement? American Board of Internal Medicine Foundation American College of Physicians Society of Hospital Medicine Care Transitions Performance Measurement Set for Inpatient Discharges & Emergency Department Discharges. Numerator Element Definitions:a. Transition record: a core, standardized set of data elements related to patient’s diagnosis, treatment, and care plan that is discussed with and provided to patient in printed or electronic format at each transition of care, and transmitted to the facility/physician/other health care professional providing follow-up care. Electronic format may be provided only if acceptable to patient.b. Current medication list: all medications to be taken by patient after discharge, including all continued and new medicationsc. Advance directives: eg, written statement of patient wishes regarding future use of life-sustaining medical treatmentd. Documented reason for not providing advance care plan: documentation that advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan, OR documentation as appropriate that the patient's cultural and/or spiritual beliefs preclude a discussion of advance care planning as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patient relationshipe. Contact information/ plan for follow-up care: For patients discharged to an inpatient facility, the transition record may indicate that these four elements are to be discussed between the discharging and the “receiving” facilities.f. Plan for follow-up care: may include any post-discharge therapy needed (eg, oxygen therapy, physical therapy, occupational therapy), any durable medical equipment needed, family/psychosocial resources available for patient support, etc.g. Primary physician or other health care professional designated for follow-up care: may be designated primary care physician (PCP), medical specialist, or other physician or health care professionalB1-287: Documentation of Current Medications in the Medical RecordMeasure Description:Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administrationB1-287: Documentation of Current Medications in the Medical RecordDY7/DY8 Program IDB1-287Measure DetailsSteward: CMSNQF #: 0419Source: CMS MIPS #130 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll visits for patients aged 18 years and olderDenominator InclusionsCLAIMS/REGISTRY:Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439 E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: Medications Encounter Code Set" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician (G8430) E.H.R.:None Denominator Exceptions = OR: "Procedure, Performed not done: Medical or Other reason not done" for "Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"Numerator DescriptionEligible clinician attests to documenting, updating or reviewing a patient’s current medications using all resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administrationDefinitions:Current Medications – Medications the patient is presently taking including all prescriptions, over-the- counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.Route – Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical)Not Eligible (Denominator Exception) – A patient is not eligible if the following reason is documented:?Patient is in an urgent or emergent medical situation where time is of the essence and to delaytreatment would jeopardize the patient’s health statusNUMERATOR NOTE: The eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible clinician documented that the patient is not currently taking any medicationsNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications (G8427) E.H.R.: AND: "Procedure, Performed: Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given (G8428) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationE.H.R.:Data Criteria (QDM Data Elements):? "Encounter, Performed: Medications Encounter Code Set" using "Medications Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1834)"? "Procedure, Performed: Current Medications Documented SNMD" using "Current Medications Documented SNMD SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.462)"? "Procedure, 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)"B1-352: Post-Discharge AppointmentMeasure Description:Rate 1 (2455): Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of heart failure for whom a follow up appointment was scheduled and documented prior to discharge (as specified) Rate 2 (2439): Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.B1-352: Post-Discharge AppointmentDY7/DY8 Program IDB1-352Measure DetailsSteward: Rate 1 NQF #2455: AHA/ASARate 2 NQF #2439: TJCNQF #: 2455 & 2439Source: 2455: : SourceClaimsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 (2455): All patients, regardless of age, discharged from an inpatient facility (ie, hospital inpatient or observation) to ambulatory care (home/self care) of home health care with a principle discharge diagnosis of heart failure** Rate 2 (2439): All heart failure** patients discharged from a hospital inpatient setting to home or home care.Denominator InclusionsRate 1: Age: 2.16.840.1.113883.3.560.100.4AND DIAGNOSIS Active Heart Failure: 2.16.840.1.113883.3.526.3.376 AND ATTRIBUTE Ordinality Principal Discharge Diagnosis: 2.16.840.1.113883.3.526.3.1519AND Encounter Performed Discharge Services – Hospital Inpatient: 2.16.840.1.113883.3.464.1003.101.12.1007 OR ENCOUNTER Performed Discharge Services – Hospital Inpatient Same Day Discharge: 2.16.840.1.113883.3.464.1003.101.12.1006ANDATTRIBUTE Discharge Status Discharge To Home: 2.16.840.1.113883.3.526.3.1512 (NOTE: CHF Diagnosis include: I11.0, I13.0, I13.2, I50.1, I50.20, I50.21, I50.22, I50.23, I50.30, I50.31, I50.32, I50.33, I50.40, I50.41, I50.42, I50.43, I50.9) Rate 2:Discharges with ICD-10-CM Principal Diagnosis Code for HFANDA discharge to home, home care, or court/law enforcementDenominator ExclusionsRate 1 (NQF 2455): DENOMINATOR EXCLUSIONS: Patient was discharged to a health care facility for hospice care, to home for hospice care, or to a rehabilitation facility.ORPatient left against medical advice.ORPatient expired. DENOMINATOR EXLCUSION LOGIC:All Patients Identified in the DenomiantorAND ENCOUNTER Performed, Discharge Services – Hospital Inpatient: 2.16.840.1.113883.3.464.1003.101.12.1007 OR ENCOUNTER Performed, Discharge Services – Hospital Inpatient Same Day Discharge: 2.16.840.1.113883.3.464.1003.101.12.1006AND ATTRIBUTE Discharge Status, Patient Expired: 2.16.840.1.113883.3.117.1.7.1.86 OR ATTRIBUTE Discharge Status, Left Against Medical Advice: 2.16.840.1.113883.3.526.3.1517 OR ATTRIBUTE Discharge Status, Discharge to Health Care Facility for Hospice Care: 2.16.840.1.113883.3.526.3.1514 OR ATTRIBUTE Discharge Status, Discharged to Home for Hospice Care: 2.16.840.1.113883.3.526.3.1515 OR ATTRIBUTE Discharge Status, Discharged to Rehabilitation Facility: 2.16.840.1.113883.3.526.3.1516 DENOMINATOR EXCEPTIONS (excluded from denonominator based on criteria identified in numerator):Documentation of medical reason(s) for not documenting that a follow up appointment was scheduledORDocumentation of patient reason(s) for not documenting that a follow up appointment was scheduled (eg, international patients,patients from state and/or local corrections facilities for whom scheduling the appointment is prohibited) DENOMINATOR EXCEPTION LOGIC: All Patients Identified within the DenominatorAND NOTAll Patients Identified within the NumeratorAND ATTRIBUTE Discharge Status Discharge To Policy Custody: 2.16.840.1.113883.3.526.3.1513 AND ENCOUNTER Performed, Discharge Services – Hospital Inpatient: 2.16.840.1.113883.3.464.1003.101.12.1007 OR ENCOUNTER Performed, Discharge Services – Hospital Inpatient Same Day Discharge: 2.16.840.1.113883.3.464.1003.101.12.1006ORENCOUNTER Not Ordered, Office Visit: 2.16.840.1.113883.3.464.1003.101.12.1001; Attribute: Negation Rationale, Medical Reason: 2.16.840.1.113883.3.526.3.1007; Attribute: Negation Rationale, Patient Reason: 2.16.840.1.113883.3.526.3.1008ORENCOUNTER Not Ordered, Home Healthcare Services: 2.16.840.1.113883.3.464.1003.101.12.1016Attribute: Negation Rationale, Medical Reason: 2.16.840.1.113883.3.526.3.1007Attribute: Negation Rationale, Patient Reason: 2.16.840.1.113883.3.526.3.1008ORINTERVENTION Not Ordered, Follow-Up Appointment Scheduled: 2.16.840.1.113883.3.526.3.1518Attribute: Negation Rationale, Medical Reason: 2.16.840.1.113883.3.526.3.1007Attribute: Negation Rationale, Patient Reason: 2.16.840.1.113883.3.526.3.1008 Rate 2 (NQF 2439): Excluded Populations:? Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A, Table 2.2)? Patients less than 18 years of age? Patient who have a Length of Stay greater than 120 days? Patients with Comfort Measures Only documented? Patients enrolled in a Clinical Trial? Patients discharged to locations other than home, home care, or law enforcement? Patients with a documented Reason for No Post-Discharge Appointment Within 7 Days? Patients who left against medical advice (AMA)Numerator Description2455: Patients for whom a follow up appointment was scheduled and documented prior to discharge including either: - an office visit for management for heart failure with a physician OR advanced practice nurse OR physician assistant OR- a home health visit for management of heart failure NOTE: Due to the nature of scheduling home health visits, the location and date of the follow-up appointment is sufficient for meeting themeasure 2439: Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.Numerator Inclusions (Performance Met)Rate 1 (NQF 2455): LOGIC: All Patients Identified within the DenominatorAND ENCOUNTER Order, Office Visit: 2.16.840.1.113883.3.464.1003.101.12.1001 OR ENCOUNTER Order, Home Healthcare Services: 2.16.840.1.113883.3.464.1003.101.12.1016 OR INTERVENTION Order, Follow-Up Appointment Scheduled: 2.16.840.1.113883.3.526.3.1518 Rate 2: Y (Yes) A follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.Numerator Exclusions (Performance Not Met)Rate 1:None Specified Rate 2:N (No) A follow-up appointment for an office or home health visit for management of heart failure was not scheduled within 7 days post-discharge and documented including location, date, and time, OR unable to determine from medical record documentation.DSRIP Specific ModificationsNOTE: For DSRIP reporting purposes, providers may identify a single methodology for identifying the denominator for both rate 1 and rate 2. Post-discharge appointment should be scheduled prior to discharge or the end of the next business day if dischargeAdditional InformationRate 2: See measure steward specifications for applicable codes and sampling methodology. NOTES FOR ABSTRACTION- A follow-up appointment is an appointment with a physician/APN/PA in a physician office or ambulatory care clinic OR a home health visit with a RN/APN for professional nursing services that occurs within 7 days of discharge from the inpatient setting.- Follow-up scheduled within 7 days via telemedicine/teleconference to assess the patient in the home setting should be treated as a home health visit, select “Yes”.- Documentation of the scheduled office appointment must include location, date and time in order to select “Yes”. If all three pieces of information are not documented, select “No.- Documentation of a home health visit must include the date in order to select Yes. Documentation of the time is optional only for a home health visit, as the time of the visit may vary.- If the follow-up appointment is scheduled beyond 7 days post-discharge, select “No”. Suggested Data Sources: - Nursing notes- Progress notes- Physician orders- Discharge summary- Discharge instruction sheet- Home health referral formBundle B2 Patient Navigation & ED DiversionMeasure Bundle ObjectivesUtilize patient navigators (community health workers, case managers, or other types of professionals) and/or develop other strategies to provide enhanced social support and culturally competent care to connect high risk patients to primary care or medical home sites, improve patient outcomes, and divert patients needing non-urgent care to appropriate settings.Target PopulationIndividuals with at least one emergency department encounter during the measurement yearRelated System ComponentsHospitalNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNoMeasures Hospital BasedServicesNoB2-242: 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- DiabetesB2-242: Reduce Emergency Department visits for Chronic Ambulatory Care Sensitive Conditions (ACSC)DY7/DY8 Program IDB2-242Measure DetailsSteward: NANQF #: NASource: SourceClaims, E.H.R.Required StatusRequired to select at least one clinical required measure with additional points for further selectionsMeasure 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, I16 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.B2-387: 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 conditionsB2-387: Reduce Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)DY7/DY8 Program IDB2-387Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusRequired to select at least one clinical required measure with additional points for further selectionsMeasure 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 DescriptionTotal number of ED visits for individuals 18 years or older during the measurement periodDenominator 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 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.B2-392: Reduce Emergency Department visits for Acute Ambulatory Care Sensitive Conditions (ACSC)Measure Description:Rate of Emergency Department (ED) utilization for ACSC:B2-392: Reduce Emergency Department visits for Acute Ambulatory Care Sensitive Conditions (ACSC)DY7/DY8 Program IDB2-392Measure DetailsSteward: NANQF #: NASource: SourceClaims, E.H.R.Required StatusRequiredMeasure 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 (or secondary if specified) acute ACSC diagnosis for any individual 18 years and older during the measurement periodNumerator Inclusions (Performance Met)All of the following: - Bacterial pneumonia [J13, J14, J153, J154, J157, J159, J16, J18] Exclude case with secondary diagnosis of sickle cell [D57] and patients < 2 months- Cellulitis [L03, L04, L08, L88, L980] Exclude cases with a surgical procedure [starting with 0 or 1], except incision of skin and subcutaneous tissue [0H, 0J, 0W, OX] where it is the only listed surgical procedure- Convulsions [R56]- Dehydration - volume depletion [E86] Examine principal and secondary diagnoses separately- Gastroenteritis [K529, K5289]- Hypoglycemia [E162]- Kidney/urinary infection [N10, N11, N12]- Pelvic inflammatory disease [N70, N73] Women only denominator - exclude cases with a surgical procedure of hysterectomy [0UT]- Severe ENT infections [H66, J02, J03, J06, J312] Exclude otitis media cases [H66, H67] with myringotomy with insertion of tube [Z9622]- Skin grafts with cellulitis [DRG 263, DRG 264] Exclude admissions from SNF/ICFNumerator 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.NOTE: MS-DRG codes 573, 574, and 575 should be used for skin grafts with cellulitis.B2-393: Reduce Emergency Department visits for Dental ConditionsMeasure Description:Rate of ED utilization for dental conditionsB2-393: Reduce Emergency Department visits for Dental ConditionsDY7/DY8 Program IDB2-393Measure DetailsSteward: NANQF #: NASource: SourceClaims, E.H.R.Required StatusRequired to select at least one clinical required measure with additional points for further selectionsMeasure 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 diagnosis of specified dental conditions for any individual 18 years and older during the measurement periodNumerator Inclusions (Performance Met)Dental: K02, K03, K04, K05, K060, K061, K062, K08, K12, K13, M276, A690, K098Numerator 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.Bundle C1 Primary Care Prevention - Healthy TexansMeasure Bundle ObjectivesProvide comprehensive, integrated primary care services that are focused on person-centered preventive care and chronic disease screening.Target PopulationDSRIP attributed individuals age 18 or older at the beginning of the measurement period that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement period-----Exclude individuals enrolled in hospice during the measurement yearRelated System ComponentsPrimary care, specialty care where primary care is managedNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesC1-105: 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 userC1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionDY7/DY8 Program IDC1-105Measure DetailsSteward: NCQANQF #: 0028Source: CMS MIPS #226 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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.: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" Numerator 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.:NoneDSRIP 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)"C1-113: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testingMeasure Description:The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received an HbA1c test during the measurement year.C1-113: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testingDY7/DY8 Program IDC1-113Measure DetailsSteward: NCQANQF #: 0057Source: CMS Adult Core SetData SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.9288MPL: 0.8298National 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 89.43% and DY8 goal will be 89.78%.Denominator DescriptionPatients 18 - 75 years of age with diabetes with a visit during the measurement periodDenominator InclusionsPatients 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, G0439Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215 to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsHospice services provided to patient any time during the measurement period: G9687Numerator DescriptionAn HbA1c test (HbA1c Tests Value Set) performed during the measurement yearNumerator Inclusions (Performance Met)HEDIS 2017 HbA1C Value Set: 3044FOR3045FOR 3046FOR83036OR83037Numerator Exclusions (Performance Not Met)Hemoglobin A1c level was not performed during the measurement period (12 months) (3046F with 8P)DSRIP Specific ModificationsDenominator has been modified to follow the registry specifications of measures A1-116, A1-115, A1-111.Additional InformationNoneC1-147: 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 < 25C1-147: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-UpDY7/DY8 Program IDC1-147Measure 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 StatusRequiredMeasure 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 goall will be 89.35% and DY8 goal will be 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)"C1-268: Pneumonia vaccination status for older adultsMeasure Description:Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.C1-268: Pneumonia vaccination status for older adultsDY7/DY8 Program IDC1-268Measure DetailsSteward: CMSNQF #: 0043Source: CMS MIPS #111 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 periodDENOMINATOR 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, G043999387, 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/E&M codes 99201 -99205 and 99211 - 99215, office visit value set, and face-to-face- interaction value sets, to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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 ModificationsNoneAdditional 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)"C1-269: 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 immunizationC1-269: Preventive Care and Screening: Influenza ImmunizationDY7/DY8 Program IDC1-269Measure DetailsSteward: AMA / PCPINQF #: 0041 / 3070 eMeasureSource: CMS MIPS #110 (Claims/Registry) eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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)"C1-272: 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 - Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older- One influenza within last year- Herpes zoster/shingles (patients 60 years and older)C1-272: Adults (18+ years) Immunization statusDY7/DY8 Program IDC1-272Measure 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 StatusRequiredMeasure 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 InclusionsEHR: "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"Note: Providers should limit office visit value set, and face-to-face-interaction value sets, to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator 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 C1-268 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 ModificationsMeasure is based on current guidelines as outlined by the Institute for Clinical System Improvement and current CDC guidelines. For DSRIP reporting purposes, a denominator has been defined.Additional 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. C1-280: 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.C1-280: Chlamydia Screening in Women (CHL)DY7/DY8 Program IDC1-280Measure DetailsSteward: NCQANQF #: 0033Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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 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"Note: Providers should limit office visit value set, and face-to-face- interaction value sets, to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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)"C1-389: Human Papillomavirus Vaccine (age 18 -26)Measure Description:Patients 18 - 26 during the measurement year who have had the recommended HPV dosesC1-389: Human Papillomavirus Vaccine (age 18 -26)DY7/DY8 Program IDC1-389Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusRequiredMeasure 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 DescriptionAdolescents ages 18 to 26 at the beginning of the measurement yearDenominator InclusionsPatient 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, G040299383, 99384, 99385, 99393, 99394, 99395Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215 to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsDenominator Exclusions: Patients with immunization contraindications listed in the medical record should be excludedNumerator DescriptionAdolescents who had the recommended number of the HPV vaccine doses (based on age at administration of first dose), with different dates of service, between their 9th and 27th birthdays.The number of recommended doses is based on age at administration of first dose. For persons initiating vaccination before age 15, the recommended immunization schedule is 2 doses of HPV at 0, 6 - 12 months. For persons initiating vaccination at age 15 years or older, the recommended immunization schedule is 3 doses of HPV vaccine at 0, 1-2, 6 months.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNAAdditional InformationProviders selecting both C1-389 HPV (age 18 - 26) and D1-389 (HPV age 15 - 18) should include individuals age 18 during at the beginning of the measurement year in measure D1-389, and exclude individuals age 18 at the beginning of the measurement year from measure C1-389C1-502: PQI 91 Acute Composite (Adult Dehydration, Bacterial Pneumonia, Urinary Tract Infection Admission Rates)Measure Description:Prevention Quality Indicators (PQI) composite of acute conditions per 100,000 population, ages 18 years and older. Includes admissions with a principal diagnosis of one of the following conditions: dehydration, bacterial pneumonia, or urinary tract infection.C1-502: PQI 91 Acute Composite (Adult Dehydration, Bacterial Pneumonia, Urinary Tract Infection Admission Rates)DY7/DY8 Program IDC1-502Measure DetailsSteward: AHRQNQF #: NASource: AHRQ: SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionDischarges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs:? PQI #10 Dehydration Admission Rate? PQI #11 Bacterial Pneumonia Admission Rate? PQI #12 Urinary Tract Infection Admission RateDischarges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator.Numerator Inclusions (Performance Met)PQI #10 Dehydration Admission RateDischarges, for patients ages 18 years and older, with either? a principal ICD-10-CM diagnosis code for dehydration; (ACSDEHD*) or? any secondary ICD-10-CM diagnosis codes for dehydration (ACSDEHD*) and a principal ICD-10-CM diagnosis code for hyperosmolality and/or hypernatremia (HYPERID*), or a principal ICD-10-CM diagnosis code for gastroenteritis (ACPGASD*), or a principal ICD-10-CM diagnosis code for acute kidney injury (PHYSIDB*) PQI #11 Bacterial Pneumonia Admission RateDischarges, for patients ages 18 years and older, with a principal ICD-10-CM diagnosis code for bacterial pneumonia (ACSBACD*). PQI #12 Urinary Tract Infection Admission RateDischarges, for patients ages 18 years and older, with a principal ICD-10-CM diagnosis code for urinary tract infection (ACSUTID*).Numerator Exclusions (Performance Not Met)PQI #10 Dehydration Admission RateExclude cases:? transfer from a hospital (different facility) (Appendix A)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix A)? transfer from another health care facility (Appendix A)? with any-listed ICD-10-CM diagnosis codes for chronic renal failure (CRENLFD*)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing) PQI #11 Bacterial Pneumonia Admission RateExclude cases:? transfer from a hospital (different facility) (Appendix A)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix A)? transfer from another health care facility (Appendix A)? with any-listed ICD-10-CM diagnosis codes for sickle cell anemia or HB-S disease (ACSBA2D*)? with any-listed ICD-10-CM diagnosis codes (Appendix C) or any-listed ICD-10-PCS procedure codes for immunocompromised state (Appendix C)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing) PQI #12 Urinary Tract Infection Admission RateExclude cases:? transfer from a hospital (different facility) (Appendix A)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix A)? transfer from another health care facility (Appendix A)? with any-listed ICD-10-CM diagnosis codes for kidney/urinary tract disorder (KIDNEY*)? with any-listed ICD-10-CM diagnosis codes (Appendix C) or any-listed ICD-10-PCS procedure codes for immunocompromised state ((Appendix C)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing) obstetric discharges should not be considered in the PQI rateDSRIP Specific ModificationsSpecified that denominator is the DSRIP Attributed Target Population. Admissions should be limited to individuals from the DSRIP attributed target population.Additional InformationSee measure source for included and excluded valuesBundle C2 Primary Care Prevention - Cancer ScreeningMeasure Bundle ObjectivesIncrease access to cancer screening in the primary care setting.Target PopulationDSRIP attributed individuals age 18 or older at the beginning of the measurement period that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement period-----Exclude individuals enrolled in hospice during the measurement yearRelated System ComponentsPrimary care, specialty care where primary care is managedNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoC2-106: Cervical Cancer ScreeningMeasure Description:Percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria:- Women age 21–64 who had cervical cytology performed every 3 years.- Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.C2-106: Cervical Cancer ScreeningDY7/DY8 Program IDC2-106Measure DetailsSteward: NCQANQF #: 0032Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure ClassificationType: Cancer ScreeningMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.6983MPL: 0.4834National 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 23-64 years of age with a visit during the measurement period. Exclusions: Women who had a hysterectomy with no residual cervix. Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: Age>= 23 year(s) at: "Measurement Period" AND: Age< 64 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" during "Measurement Period"Note: Providers should limit office visit value set, and face-to-face- interaction value sets, to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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: "Procedure, Performed: Hysterectomy with No Residual Cervix" ends before end of "Measurement Period"Numerator DescriptionWomen with one or more screenings for cervical cancer. Appropriate screenings are defined by any one of the following criteria:- Cervical cytology performed during the measurement period or the two years prior to the measurement period for women who are at least 21 years old at the time of the test- Cervical cytology/human papillomavirus (HPV) co-testing performed during the measurement period or the four years prior to the measurement period for women who are at least 30 years old at the time of the testNumerator Inclusions (Performance Met)AND: OR: "Laboratory Test, Performed: Pap Test (result)" < 3 year(s) ends before end of "Measurement Period" OR: AND: Age>= 30 year(s) at: "Occurrence A of Laboratory Test, Performed: Pap Test" AND: "Occurrence A of Laboratory Test, Performed: Pap Test" satisfies all: (result) < 5 year(s) ends before end of "Measurement Period" satisfies any: <= 1 day(s) starts after or concurrent with start of "Laboratory Test, Performed: HPV Test (result)" <= 1 day(s) starts before start of "Laboratory Test, Performed: HPV Test (result)"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:- To ensure the measure is only looking for a cervical cytology test only after a woman turns 21 years of age, the youngest age in the initial population is 23.- 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.- Include only cytology and HPV co-testing; in co-testing, both cytology and HPV tests are performed (i.e., the samples are collected and both tests are ordered, regardless of the cytology result) on the same date of service. Do not include reflex testing. In addition, if the medical record indicates the HPV test was performed only after determining the cytology result, this is considered reflex testing and does not meet criteria for the measure. Data Criteria (QDM Data Elements)? "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: HPV Test" using "HPV Test Grouping Value Set (2.16.840.1.113883.3.464.1003.110.12.1059)"? "Laboratory Test, Performed: Pap Test" using "Pap Test Grouping Value Set (2.16.840.1.113883.3.464.1003.108.12.1017)"? "Patient Characteristic Sex: Female" using "Female AdministrativeGender Value Set (2.16.840.1.113883.3.560.100.2)"? "Procedure, Performed: Hysterectomy with No Residual Cervix" using "Hysterectomy with No Residual Cervix Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1014)"? 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)"C2-107: Colorectal Cancer ScreeningMeasure Description:The percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer.C2-107: Colorectal Cancer ScreeningDY7/DY8 Program IDC2-107Measure DetailsSteward: NCQANQF #: 0034Source: CMS MIPS #113 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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, G043999386, 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"Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215, office visit value set, and face-to-face- interaction value sets, to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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 ModificationsNoneAdditional 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)"C2-186: Breast Cancer ScreeningMeasure Description:The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.C2-186: Breast Cancer ScreeningDY7/DY8 Program IDC2-186Measure DetailsSteward: NCQANQF #: 2372Source: CMS MIPS #112 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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, G043999386, 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"Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215, office visit value set, and face-to-face- interaction value sets, to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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 ModificationsNoneAdditional 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)"Bundle C3 Hepatitis CMeasure Bundle ObjectivesImplement screening program in high risk populations to detect and treat Hepatitis C infections.Target PopulationDSRIP attributed individuals age 18 or older at the beginning of the measurement period that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement period-----Exclude individuals enrolled in hospice during the measurement yearRelated System ComponentsPrimary care, specialty care where primary care is managedNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoC3-203: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at RiskMeasure Description:Percentage of patients aged 18 years and older with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 who received one- time screening for hepatitis C virus (HCV) infectionC3-203: Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at RiskDY7/DY8 Program IDC3-203Measure DetailsSteward: AMA-PCPINQF #: NA / 3059 eMeasureSource: CMS MIPS #400 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure 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 who were seen twice for any visit or who had at least one preventive visit within the 12 month reporting period with one or more of the following: a history of injection drug use, receipt of a blood transfusion prior to 1992, receiving maintenance hemodialysis, OR birthdate in the years 1945–1965 DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures.Denominator InclusionsPatients aged ≥ 18 yearsANDAt least one preventive encounter during the performance period (CPT or HCPCS): 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439WITHOUT:Telehealth Modifier: GQ, GTORAt least two patient encounters during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241*, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350WITHOUT:Telehealth Modifier: GQ, GTANDPatients who were born in the years 1945 to 1965: G9448ORHistory of receiving blood transfusions prior to 1992: G9449ORReceiving maintenance hemodialysis (CPT): 90951, 90952, 90953, 90954, 90955, 90956, 90957, 90958, 90959, 90960, 90961, 90962, 90963, 90964, 90965, 90966, 90967, 90968, 90969, 90970, 99512*ORHistory of injection drug use: G9450Denominator ExclusionsDiagnosis for Chronic Hepatitis C (ICD-10-CM): B18.2ORDocumentation of medical reason(s) for not receiving one-time screening for HCV infection (e.g., decompensated cirrhosis indicating advanced disease [ie, ascites, esophageal variceal bleeding, hepatic encephalopathy], hepatocellular carcinoma, waitlist for organ transplant, limited life expectancy, other medical reasons) (G9452)ORDocumentation of patient reason(s) for not receiving one-time screening for HCV infection (e.g., patient declined, other patient reasons) (G9453)Numerator DescriptionPatients who received one-time screening for HCV infection Definition:Screening for HCV Infection includes current or prior receipt of:1. HCV antibody test2. HCV RNA test3. Recombinant immunoblot assay (RIBA) test (if performed at any time in the past)Numerator Inclusions (Performance Met)Patient received one-time screening for HCV infection (G9451)Numerator Exclusions (Performance Not Met)One-time screening for HCV infection not received within 12 month reporting period and no documentation of prior screening for HCV infection, reason not given (G9454)DSRIP Specific ModificationsNoneAdditional InformationNoneC3-328: Appropriate Screening Follow-up for Patients Identified with Hepatitis C Virus (HCV) Infection (eMeasure)Measure Description:Percentage of patients aged 18 years and older with either (1) a positive HCV antibody test result and a positive HCV RNA test result 1or (2) a positive HCV antibody test result and an absent HCV RNA test result who are prescribed treatment or are referred to evaluation or treatment servicesC3-328: Appropriate Screening Follow-up for Patients Identified with Hepatitis C Virus (HCV) Infection (eMeasure)DY7/DY8 Program IDC3-328Measure DetailsSteward: AMA-PCPINQF #: 3061Source: SourceE.H.R.Required StatusRequiredMeasure 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 who are seen twice for any visit or who had at least one preventive visit with either (1) a positive HCV antibody test result and a positive HCV RNA test result or (2) a positive HCV antibody test result and an absent HCV RNA test resultDenominator InclusionsPopulation Criteria 1:Initial Population = AND: Age >= 18 year(s) at: "Measurement Period" AND: OR: Count >= 1 of: $OutpatientPreventiveEncounters OR: Count >= 2 of: $OutpatientNonPreventiveEncountersDenominator = AND: Initial Population AND: "Occurrence A of Laboratory Test, Performed: HCV Antibody Test (result: Positive Finding)" during "Measurement Period" AND: "Occurrence A of Laboratory Test, Performed: HCV RNA Test (result: Positive Finding)" <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV Antibody Test" Population Criteria 2:Initial Population = AND: Age >= 18 year(s) at: "Measurement Period" AND: OR: Count >= 1 of: $OutpatientPreventiveEncounters OR: Count >= 2 of: $OutpatientNonPreventiveEncountersDenominator = AND: Initial Population AND: "Occurrence A of Laboratory Test, Performed: HCV Antibody Test (result: Positive Finding)" during "Measurement Period" AND NOT: "Laboratory Test, Performed: HCV RNA Test (result)" <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV Antibody Test"Denominator ExclusionsPopulation Criteria 1: Denominator Exclusions = OR: "Diagnosis: Chronic Hepatitis C" overlaps "Measurement Period"Denominator Exceptions = OR: Union of: - "Patient Characteristic Clinical Trial Participant: Clinical Trial Participant" - "Diagnosis: Limited Life Expectancy" - "Diagnosis: Decompensated Cirrhosis" - "Diagnosis: Hepatocellular Carcinoma" - "Diagnosis: Waitlist for Organ Transplant" - overlaps "Measurement Period" OR: Union of: - "Medication, Order not done: Medical Reason" for "Hepatitis C Pharmacotherapy" - "Medication, Order not done: Patient Reason" for "Hepatitis C Pharmacotherapy" - "Procedure, Performed not done: Medical Reason" for "Referral for evaluation or treatment services" - "Procedure, Performed not done: Patient Reason" for "Referral for evaluation or treatment services" - <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV RNA Test" Population Criteria 2:Denominator Exclusions = OR: "Diagnosis: Chronic Hepatitis C" overlaps "Measurement Period" OR: "Laboratory Test, Performed: HCV RNA Test (result)" <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV Antibody Test"Denominator Exceptions = OR: Union of: - "Diagnosis: Limited Life Expectancy" - "Diagnosis: Decompensated Cirrhosis" - "Diagnosis: Hepatocellular Carcinoma" - "Diagnosis: Waitlist for Organ Transplant" - overlaps "Measurement Period" OR: Union of: - "Procedure, Performed not done: Medical Reason" for "Referral for evaluation or treatment services" - "Procedure, Performed not done: Patient Reason" for "Referral for evaluation or treatment services" - <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV Antibody Test"Numerator DescriptionPatients who are prescribed treatment or are referred to evaluation or treatment services *Numerator Note: To meet the numerator for this measure, patients with an absent HCVRNA test result must be referred to evaluation or treatment services within 90 daysfollowing a positive HCV antibody test result, while patients with a positive HCV RNA testresult must be either prescribed treatment or referred to evaluation or treatmentservices within 90 days following a positive HCV RNA test resultNumerator Inclusions (Performance Met)Population Criteria 1:Numerator = AND: Union of: "Medication, Active: Hepatitis C Pharmacotherapy" "Medication, Order: Hepatitis C Pharmacotherapy" "Procedure, Performed: Referral for evaluation or treatment services" <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV RNA Test (result: Positive Finding)" Population Criteria 2:Numerator = AND: "Procedure, Performed: Referral for evaluation or treatment services" <= 90 day(s) starts after start of "Occurrence A of Laboratory Test, Performed: HCV Antibody Test (result)"Numerator Exclusions (Performance Not Met)None specifiedDSRIP Specific ModificationsFor DSRIP reporting purposes, the denominator is the sum of Population Criteria 1 and Population Criteria 2, and the numerator is the sum of Population Criteria 1 and Population Criteria 2.Additional InformationNoneC3-368: Hepatitis C: Hepatitis A VaccinationMeasure Description:Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis A vaccine, or who have documented immunity to hepatitis AC3-368: Hepatitis C: Hepatitis A VaccinationDY7/DY8 Program IDC3-368Measure DetailsSteward: NoneNQF #: 0399Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionAll patients aged 18 years and older with a diagnosis of chronic hepatitis CDenominator Inclusions "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" during "Measurement Period"Note: Providers should limit office visit value set and face-to-face- interaction value sets to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsDocumentation of medical reason(s) for not administering at least one injection of hepatitis A vaccine (eg, allergy or intolerance to a known component of the vaccine, other medical reasons) Documentation of patient reason(s) for not administering at least one injection of hepatitis A vaccine (eg, patient declined, insurance coverage, other patient reasons)Numerator DescriptionPatients who have received at least one injection of hepatitis A vaccine, or who have documented immunity to Hepatitis ANumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, an encounter history has been defined for denominator inclusion. Additional InformationData Criteria (QDM Variables):Encounter, Performed: Office Visit: 2.16.840.1.113883.3.464.1003.101.12.1001Encounter, Performed: Face-to-Face Interaction: 2.16.840.1.113883.3.464.1003.101.12.1048Encounter, Performed: Home Healthcare Services: 2.16.840.1.113883.3.464.1003.101.12.1016Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up: 2.16.840.1.113883.3.464.1003.101.12.1025Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up: 2.16.840.1.113883.3.464.1003.101.12.1023C3-369: Hepatitis C: Hepatitis B VaccinationMeasure Description:Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who have received at least one injection of hepatitis B vaccine, or who have documented immunity to hepatitis BC3-369: Hepatitis C: Hepatitis B VaccinationDY7/DY8 Program IDC3-369Measure DetailsSteward: NoneNQF #: 0400Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionAll patients aged 18 years and older with a diagnosis of hepatitis CDenominator Inclusions "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" during "Measurement Period"Note: Providers should limit office visit value set and face-to-face-interaction value sets to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsDocumentation of medical reason(s) for not receiving at least one injection of hepatitis B vaccineDocumentation of patient reason(s) for not receiving at least one injection of hepatitis B vaccineNumerator DescriptionPatients who have received at least one injection of Hepatitis B vaccine, or who have documented immunity to Hepatitis BNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, an encounter history has been defined for denominator inclusion. Additional InformationData Criteria (QDM Variables):Encounter, Performed: Office Visit: 2.16.840.1.113883.3.464.1003.101.12.1001Encounter, Performed: Face-to-Face Interaction: 2.16.840.1.113883.3.464.1003.101.12.1048Encounter, Performed: Home Healthcare Services: 2.16.840.1.113883.3.464.1003.101.12.1016Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up: 2.16.840.1.113883.3.464.1003.101.12.1025Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up: 2.16.840.1.113883.3.464.1003.101.12.1023Bundle D1 Pediatric Primary CareMeasure Bundle ObjectivesIncrease access to comprehensive, coordinated primary care & preventive services focused on accountable, child-centered care that improves quality of life and health outcomes.Target PopulationDSRIP attributed individuals age 21 and younger at the beginning of the measurement period that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement period----Exclude individuals enrolled in hospice during the measurement yearRelated System ComponentsPrimary care, specialty care where primary care is managedNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesD1-108: 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.D1-108: Childhood Immunization Status (CIS)DY7/DY8 Program IDD1-108Measure DetailsSteward: NCQANQF #: 0038Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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 will be 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"Note: Providers should limit office visit value set and face-to-face- interaction value sets to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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 InformationGuidance:- For the MMR, hepatitis B, VZV and hepatitis A vaccines, numerator inclusion criteria include: evidence of receipt of the recommended vaccine; documented history of the illness; or, a seropositive test result for the antigen. For the DTaP, IPV, HiB, pneumococcal conjugate, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine. Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin. Patients may be included in the numerator for the influenza, MMR, or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodefiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker's yeast.- The measure allows a grace period by measuring compliance with these recommendations between birth and age two. Data Criteria (QDM Variables)? $DTaPVaccine = o Union of: "Immunization, Administered: DTaP Vaccine" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: DTaP Vaccine Administered" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"? $InfluenzaVaccine = o Union of: "Immunization, Administered: Influenza Vaccine" satisfies all: >= 180 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: Influenza Vaccine Administered" satisfies all: >= 180 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"? $IPVVaccine = o Union of: "Immunization, Administered: Inactivated Polio Vaccine (IPV)" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: Inactivated Polio Vaccine (IPV) Administered" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"? $PneumococcalConjugateVaccine = o Union of: "Immunization, Administered: Pneumococcal Conjugate Vaccine" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: Pneumococcal Conjugate Vaccine Administered" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"? $RotavirusVaccine3Dose = o Union of: "Immunization, Administered: Rotavirus Vaccine (3 dose schedule)" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: Rotavirus Vaccine (3 dose schedule) Administered" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"? $HepatitisBVaccine = o Union of: "Immunization, Administered: Hepatitis B Vaccine" "Procedure, Performed: Hepatitis B Vaccine Administered" <= 730 day(s) starts after or concurrent with start of "Birthdate : Patient Characteristic Birthdate"? $RotavirusVaccine2Dose = o Union of: "Immunization, Administered: Rotavirus Vaccine (2 dose schedule)" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: Rotavirus Vaccine (2 dose schedule) Administered" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"? $HIBVaccine = o Union of: "Immunization, Administered: Haemophilus Influenzae Type B (HiB) Vaccine" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" "Procedure, Performed: Haemophilus Influenzae Type B (HiB) Vaccine Administered" satisfies all: >= 42 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate" <= 730 day(s) ends after start of "Birthdate : Patient Characteristic Birthdate"Data 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)"D1-211: 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 activityD1-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ AdolescentsDY7/DY8 Program IDD1-211Measure DetailsSteward: NCQANQF #: 0024Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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%- Counseling for Nutrition: DY7 goal is 70.88% and DY8 goal of 71.74%- Counseling for Physical Activity: DY7 goal is 63.47% and DY8 goal of 64.28%Denominator 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: $OutpatientVisitsNote: Providers should limit office visit value set, and face-to-face-interaction value sets to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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: "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)"D1-212: Appropriate Testing for Children With PharyngitisMeasure Description:Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.D1-212: Appropriate Testing for Children With PharyngitisDY7/DY8 Program IDD1-212Measure DetailsSteward: AHRQNQF #: 0002Source: CMS MIPS #66 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.8659MPL: 0.6324National 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 DescriptionChildren 3 - 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of pharyngitis during the measurement period and an antibiotic ordered on or three days after the visit Denominator Instructions: To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the pharyngitis diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion. DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for registry-based measures. Aminopenicillins:- Amoxicillin- Ampicillin Beta-lactamase inhibitors:- Ampicillin clavulanate First generation cephalosporins:- Cefadroxil- Cephalexin- Cefazolin Folate antagonist:- Trimethoprim Lincomycin derivatives:- Clindamycin Macrolides:- Azithromycin- Erythromycin ethylsuccinate- Clarithromycin- Erythromycin lactobionate- Erythromycin- Erythromycin stearate Miscellaneous antibiotics:- Erythromycin-sulfisoxazole Natural penicillins:- Penicillin G potassium- Penicillin V potassium- Penicillin G sodium Penicillinase-resistant penicillins:- Dicloxacillin- Quinolones- Ciprofloxacin- Moxifloxacin- Levofloxacin- Ofloxacin Second generation cephalosporins:- Cefaclor- Cefuroxime- Cefprozil Sulfonamides:- Sulfamethoxazole-trimethoprim- Tetracyclines- Doxycycline- Tetracycline- Minocycline Third generation cephalosporins:- Cefdinir- Ceftibuten- Cefixime- Cefditoren- Cefpodoxime- CeftriaxoneDenominator InclusionsREGISTRY:Patients aged 3 to 18 years on date of encounterANDDiagnosis for pharyngitis (ICD-10-CM): J02.0, J02.8, J02.9, J03.00, J03.01, J03.80, J03.81, J03.90, J03.91ANDPatient encounter during the performance period (CPT or HCPCS): 96160, 96161, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241*, 99242*, 99243*, 99244*, 99245*, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99404*, 99411*, 99412*, 99429*, 99455, 99456, 99281, 99282, 99283, 99284, 99285, G0402ANDPrescribed or dispensed antibiotic: G8711 E.H.R.: AND: Age>= 3 year(s) at: "Measurement Period" AND: Age< 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: Ambulatory/ED Visit" satisfies all: during "Measurement Period" <= 3 day(s) starts before or concurrent with start of "Medication, Order: Antibiotic Medications for Pharyngitis" overlaps Occurrence A of $AcutePharyngitisOrTonsillitisDenominator ExclusionsREGISTRY:Patients who use hospice services any time during the measurement period: G9702ORChildren who are taking antibiotics in the 30 days prior to the diagnosis of pharyngitis: G9703 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: AND: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" <= 30 day(s) starts before start of Occurrence A of $AcutePharyngitisOrTonsillitis AND: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" >= 1 day(s) starts before start of Occurrence A of $AcutePharyngitisOrTonsillitis OR: AND: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" > 30 day(s) starts before start of Occurrence A of $AcutePharyngitisOrTonsillitis AND NOT: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" > 30 day(s) ends before start of Occurrence A of $AcutePharyngitisOrTonsillitisNumerator DescriptionChildren with a group A streptococcus test in the 7-day period from 3 days prior through 3 days after the diagnosis of pharyngitis Numerator Instructions: For performance, the measure will be calculated as the number of patient encounters where diagnosed with pharyngitis, dispensed an antibiotic and received a group A streptococcus (strep) test for the episode over the total number of encounters in the denominator (patients aged 3 to 18 years with an outpatient or ED visit and an antibiotic ordered on or three days after the visit). A higher score indicates appropriate treatment of children with pharyngitis (e.g., the proportion for whom antibiotics were prescribed with an accompanying step test).Numerator Inclusions (Performance Met)REGISTRY:Group A Strep Test Performed (3210F) E.H.R.: AND: Union of: "Laboratory Test, Performed: Group A Streptococcus Test (result)" <= 3 day(s) starts before end of "Occurrence A of Encounter, Performed: Ambulatory/ED Visit" "Laboratory Test, Performed: Group A Streptococcus Test (result)" <= 3 day(s) starts after end of "Occurrence A of Encounter, Performed: Ambulatory/ED Visit"Numerator Exclusions (Performance Not Met)REGISTRY:Group A Strep Test not Performed, reason not otherwise specified (3210F with 8P) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Variables):? $AcutePharyngitisOrTonsillitis = o Union of: "Diagnosis: Acute Pharyngitis" "Diagnosis: Acute Tonsillitis" Data Criteria (QDM Data Elements):? "Diagnosis: Acute Pharyngitis" using "Acute Pharyngitis Grouping Value Set (2.16.840.1.113883.3.464.1003.102.12.1011)"? "Diagnosis: Acute Tonsillitis" using "Acute Tonsillitis Grouping Value Set (2.16.840.1.113883.3.464.1003.102.12.1012)"? "Encounter, Performed: Ambulatory/ED Visit" using "Ambulatory/ED Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1061)"? "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"? "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: Group A Streptococcus Test" using "Group A Streptococcus Test Grouping Value Set (2.16.840.1.113883.3.464.1003.198.12.1012)"? "Medication, Active: Antibiotic Medications for Pharyngitis" using "Antibiotic Medications for Pharyngitis Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1001)"? "Medication, Order: Antibiotic Medications for Pharyngitis" using "Antibiotic Medications for Pharyngitis Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1001)"? 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)"D1-237: 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.D1-237: Well-Child Visits in the First 15 Months of Life (6 or more visits)DY7/DY8 Program IDD1-237Measure DetailsSteward: NCQANQF #: 1392Source: CMS Child Core SetData SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 visits.NOTE: For DSRIP reporting purposes, providers may include well-child visits completed by a RN under the supervision of a PCP in accordance with the Texas Health Steps program. RNs without CNS, NP, or CNM certification may provide THSteps medical checkups only under direct physician supervision, meaning the physician is either on site during the checkup or immediately available to furnish assistance and direction to the RN during the checkup. Prior to performing THSteps checkups, the RN must complete required training modules developed by THSteps. (THSteps)-Checkups.shtm Additional 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. D1-271: Immunization for AdolescentsMeasure Description:The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthdayD1-271: Immunization for AdolescentsDY7/DY8 Program IDD1-271Measure DetailsSteward: NCQANQF #: 1407Source: CMS MIPS #394 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure 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 0.2462 and DY8 goal will be 0.2520 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, G040299384, 99394Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215 to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsMeningococcal, Tdap and/or HPV vaccine contraindicated OR patient allergic to themeningococcal, 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 ofmeningococcal 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 ModificationsUnder 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 recommen 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: InformationNoneD1-284: Appropriate Treatment for Children with Upper Respiratory Infection (URI)Measure Description:Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.D1-284: Appropriate Treatment for Children with Upper Respiratory Infection (URI)DY7/DY8 Program IDD1-284Measure DetailsSteward: NCQANQF #: 0069Source: CMS MIPS #65 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.9608MPL: 0.8492National 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 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 93.38% and DY8 goal of 93.65%.Denominator DescriptionChildren age 3 months to 18 years of age who had an outpatient or emergency department (ED) visit with a diagnosis of upper respiratory infection (URI) during the measurement period Denominator Instructions: To determine eligibility, look for any of the listed antibiotic drugs below in the 30 days prior to the visit with the URI diagnosis. As long as there are no prescriptions for the listed antibiotics during this time period, the patient is eligible for denominator inclusion.Denominator InclusionsREGISTRY:Patients aged 3 months to 18 years on date of encounterANDDiagnosis for URI (ICD-10-CM): J00, J06.0, J06.9ANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99281, 99282, 99283, 99284, 99285, G0402 E.H.R.: AND: Age>= 3 month(s) at: "Measurement Period" AND: Age< 18 year(s) at: "Measurement Period" AND: "Occurrence A of Diagnosis: Upper Respiratory Infection" satisfies any: starts during Occurrence A of $URIEncounter satisfies all: starts before or concurrent with start of Occurrence A of $URIEncounter overlaps Occurrence A of $URIEncounterDenominator ExclusionsREGISTRY:Patient prescribed or dispensed antibiotic for documented medical reason(s) (e.g., intestinal infection, pertussis, bacterial infection, Lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or UTI, and acne: G8709ORChildren who are taking antibiotics in the 30 days prior to the date of the encounter during which the diagnosis was established: G9701ORPatients who use hospice services any time during the measurement period: G9700 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: AND: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" <= 30 day(s) starts before start of "Occurrence A of Diagnosis: Upper Respiratory Infection" AND: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" >= 1 day(s) starts before start of "Occurrence A of Diagnosis: Upper Respiratory Infection" OR: AND: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" > 30 day(s) starts before start of "Occurrence A of Diagnosis: Upper Respiratory Infection" AND NOT: "Occurrence A of Medication, Active: Antibiotic Medications for Pharyngitis" > 30 day(s) ends before start of "Occurrence A of Diagnosis: Upper Respiratory Infection" OR: "Diagnosis: Competing Conditions for Respiratory Conditions" <= 3 day(s) starts after start of Occurrence A of $URIEncounterNumerator DescriptionChildren without a prescription for antibiotic medication on or 3 days after the outpatient or ED visit for an upper respiratory infection Numerator Instructions: For performance, the measure will be calculated as the number of patient’s encounter(s) where antibiotics were neither prescribed nor dispensed on or within three days of the episode for URI over the total number of encounters in the denominator (patients aged 3 months to 18 years with an outpatient or ED visit for URI. A higher score indicates appropriate treatment of patients with URI (e.g., the proportion for whom antibiotics were not prescribed or dispensed following the episode). ANTIBIOTIC MEDICATIONS: Aminopenicillins: - Amoxicillin- Ampicillin Beta-lactamase inhibitors: - Amoxicillin-clavulanate First generation cephalosporins: - Cefadroxi- Cefazolin- Cephalexin Folate antagonist: - Trimethoprim Lincomycin derivatives: - Clindamycin Macrolides:- Azithromycin- Clarithromycin- Erythromycin- Erythromycin ethylsuccinate- Eythromycin lactobionate- Erythromycin stearate Miscellaneous antibiotics: - Erythromycin-sulfisoxazole Natural penicillins:- Penicillin G potassium- Penicillin G sodium- Penicillin V potassium Penicillinase-resistant penicillins:- Dicloxacillin Quinolones:- Ciprofloxacin- Levofloxacin- Moxifloxacin- Ofloxacin Second generation cephalosporins- Cefaclor- Cefprozil- Cefuroxime Sulfonamides:- Sulfamethoxazole-trimethoprim Tetracyclines:- Doxycycline- Minocycline- Tetracycline Third generation cephalosporins- Cefdinir- Cefixime- Cefpodoxime- Ceftibuten- Cefditoren- CeftriaxoneNumerator Inclusions (Performance Met)REGISTRY:Patient not prescribed or dispensed antibiotic (G8708) E.H.R.: AND NOT: "Medication, Order: Antibiotic Medications for Pharyngitis" <= 3 day(s) starts after start of Occurrence A of $URIEncounterNumerator Exclusions (Performance Not Met)Patient prescribed or dispensed antibiotic (G8710)DSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Variables)? $URIEncounter = o Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Emergency Department Visit" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Hospital Observation Care - Initial" "Encounter, Performed: Face-to-Face Interaction" during "Measurement Period" Data Criteria (QDM Data Elements)? "Diagnosis: Competing Conditions for Respiratory Conditions" using "Competing Conditions for Respiratory Conditions Grouping Value Set (2.16.840.1.113883.3.464.1003.102.12.1017)"? "Diagnosis: Upper Respiratory Infection" using "Upper Respiratory Infection Grouping Value Set (2.16.840.1.113883.3.464.1003.102.12.1022)"? "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1010)"? "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: Hospital Observation Care - Initial" using "Hospital Observation Care - Initial Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1002)"? "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)"? "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)"? "Medication, Active: Antibiotic Medications for Pharyngitis" using "Antibiotic Medications for Pharyngitis Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1001)"? "Medication, Order: Antibiotic Medications for Pharyngitis" using "Antibiotic Medications for Pharyngitis Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1001)"? 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)"D1-301: Maternal Depression ScreeningMeasure Description:The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of lifeD1-301: Maternal Depression ScreeningDY7/DY8 Program IDD1-301Measure DetailsSteward: National Committee for Quality AssuranceNQF #: 1401Source: eMeasure: SourceE.H.R.Required StatusOptional with additional points if selectedMeasure 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 DescriptionChildren with a visit who turned 6 months of age in the measurement year.Denominator InclusionsAND: OR: "Birthdate : Patient Characteristic Birthdate" <= 5 month(s) starts before start of "Measurement Period" OR: AND: "Birthdate : Patient Characteristic Birthdate" starts after start of "Measurement Period" AND: "Birthdate : Patient Characteristic Birthdate" >= 6 month(s) starts before end of "Measurement Period" AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: BH Medical or psychiatric consultation" <= 6 month(s) ends after start of "Birthdate : Patient Characteristic Birthdate"Note: Providers should limit office visit value set, and face-to-face-interaction value sets to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsNoneNumerator DescriptionChildren with documentation of maternal screening or treatment for postpartum depression for the mother.Numerator Inclusions (Performance Met)AND: Union of: "Intervention, Performed: Maternal Post Partum Depression Care" "Assessment, Performed: Maternal Post Partum Depression Screening" <= 6 month(s) ends after start of "Birthdate : Patient Characteristic Birthdate"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:The eMeasure specifies only patient's (baby) chart, looking for the newly allocated SNOMED codes that allow providers to record the screening and treatment of the mother, but the endorsed measure relies on notes from the patient's and mother's charts Data Criteria (QDM Data Elements):? "Assessment, Performed: Maternal Post Partum Depression Screening" using "Maternal Post Partum Depression Screening Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1014)"? "Encounter, Performed: BH Medical or psychiatric consultation" using "BH Medical or psychiatric consultation Grouping Value Set (2.16.840.1.113883.3.1257.1.1652)"? "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: Office Visit" using "Office Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1001)"? "Intervention, Performed: Maternal Post Partum Depression Care" using "Maternal Post Partum Depression Care Grouping Value Set (2.16.840.1.113883.3.464.1003.111.12.1013)"D1-389: Human Papillomavirus Vaccine (age 15-18)Measure Description:Patients 15 - 18 during the measurement year who have had the recommended HPV dosesD1-389: Human Papillomavirus Vaccine (age 15-18)DY7/DY8 Program IDD1-389Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusOptional with additional points if selectedMeasure ClassificationType: ImmunizationMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NADirectionality: 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 ages 15 to 18 at the beginning of the measurement yearDenominator InclusionsPatient 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, G040299383, 99384, 99385, 99393, 99394, 99395Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215 to primary care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsDenominator Exclusions: Patients with immunization contraindications listed in the medical record should be excludedNumerator DescriptionPatients who had the recommended number of the HPV vaccine doses (based on age at administration of first dose), with different dates of service, between their 9th and 19th birthdays. The number of recommended doses is based on age at administration of first dose. For persons initiating vaccination before age 15, the recommended immunization schedule is 2 doses of HPV at 0, 6 - 12 months. For persons initiating vaccination at age 15 years or older, the recommended immunization schedule is 3 doses of HPV vaccine at 0, 1-2, 6 months. Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationProviders selecting both C1-389 HPV (age 18 - 26) and D1-389 (HPV age 15 - 18) should include individuals age 18 during at the beginning of the measurement year in measure D1-389, and exclude individuals age 18 at the beginning of the measurement year from measure C1-389D1-400: 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 userD1-400: Tobacco Use and Help with Quitting Among AdolescentsDY7/DY8 Program IDD1-400Measure DetailsSteward: NCQANQF #: 2803Source: CMS MIPS #402 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure 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, G043999383, 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 ModificationsNoneAdditional InformationNoneD1-503: PDI 91 Acute Composite (Gastroenteritis, Urinary Tract Infection Admission Rate)Measure Description:Pediatric Quality Indicators (PDI) composite of acute conditions per 100,000 population, ages 3 months through 17 years. Includes admissions for gastroenteritis or urinary tract infection.D1-503: PDI 91 Acute Composite (Gastroenteritis, Urinary Tract Infection Admission Rate)DY7/DY8 Program IDD1-503Measure DetailsSteward: AHRQNQF #: NASource: AHRQ: SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target Population ages 3 months - 17 yearsDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionDischarges, for patients ages 3 months through 17 years, that meet the inclusion and exclusion rules for the numerator in any of the following PDIs:? PDI 16 Gastroenteritis Admission Rate? PDI 18 Urinary Tract Infection Admission RateDischarges that meet the inclusion and exclusion rules for the numerator in more than one of the above PDIs are counted only once in the composite numeratorNumerator Inclusions (Performance Met)PDI 16 Gastroenteritis Admission RateDischarges, for patients ages 3 months through 17 years, with either:? a principal ICD-10-CM diagnosis code for gastroenteritis (ACPGASD*)? any secondary ICD-10-CM diagnosis codes for gastroenteritis (ACPGASD*) and a principal ICD-10-CM diagnosis code for dehydration (ACSDEHD*) PDI 18 Urinary Tract Infection Admission RateDischarges, for patients ages 3 months through 17 years, with a principal ICD-10-CM diagnosis code for urinary tract infection (ACSUTID*).Numerator Exclusions (Performance Not Met)PDI 16 Gastroenteritis Admission RateExclude cases:? with any-listed ICD-10-CM diagnosis codes for gastrointestinal abnormalities (ACGDISD*)? with any-listed ICD-10-CM diagnosis codes for bacterial gastroenteritis (ACBACGD*)? transfer from a hospital (different facility)(Appendix J)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix J)? transfer from another health care facility (Appendix J)? neonates (Appendix I) if age in days is missing? MDC 14 (pregnancy, childbirth, and puerperium)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year(YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing) PDI 18 Urinary Tract Infection Admission RateExclude cases: ? with any-listed ICD-10-CM diagnosis codes for kidney/urinary tract disorder (KIDNEY*)? with any-listed ICD-10-CM diagnosis codes for high-risk immunocompromised state (Appendix F)? with any-listed ICD-10-PCS procedure codes for transplant (TRANSPP*) (high-risk immunocompromised state procedures)? with any-listed ICD-10-CM diagnosis codes for intermediate-risk immunocompromised state (including hepatic failure) (Appendix G), including cirrhosis (HEPFA2D*) and hepatic failure (HEPFA3D*)? transfer from a hospital (different facility) (Appendix J)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) (Appendix J)? transfer from another health care facility (Appendix J)? MDC 14 (pregnancy, childbirth, and puerperium)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year (YEAR=missing), principal diagnosis (DX1=missing), or county (PSTCO=missing)DSRIP Specific ModificationsSpecified that denominator is the DSRIP Attributed Target Population. Admissions should be limited to individuals from the DSRIP attributed target population.Additional InformationSee measure source for included and excluded valuesD1-T01: Innovative Measure: Behavioral Health Counselling for Childhood ObesityMeasure Description:The percentages of children/youth with BMI greater than or equal to the 95th percentile who received behavioral health counseling or family behavioral health intervention(s) as an adjunct to other interventions, or who had a follow-up BMI measurement, or had both.D1-T01: Innovative Measure: Behavioral Health Counselling for Childhood ObesityDY7/DY8 Program IDD1-T01Measure DetailsSteward: Meadows Mental Health Policy InstituteNQF #: NASource: NAData SourceE.H.R.Required StatusOptional Innovative MeasureMeasure ClassificationType: InnovativeMeasure Parts: 3Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit 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 DescriptionThe number of unduplicated children/youth ages 3 to 17 identified in the medical record with a BMI measurement greater than or equal to the 95th percentile.Denominator InclusionsChildren and youth between ages 3 to 17 yearsDenominator ExclusionsPatients with a current diagnosis of pregnancy will be excluded from the denominator and from the numerator.Numerator DescriptionThe measure will be reported by breaking out those children/youth that meet criteria specified in the denominator statement below into three separate numerator groups, each with unduplicated counts of children/youth.* Those children/youth who had:1) Two behavioral health counseling or family behavioral health interventions, recorded in the clinical record, within six (6) months of the initial BMI assessment, and had a follow-up BMI measurement, recorded in the clinical record, within six (6) months of the initial BMI measurement;2) Two behavioral health visits (defined above), but not a follow-up BMI measurement; and3) A follow-up BMI measurement (defined above), but not two behavioral health visits.*A fourth group would include children/youth who received neither a BMI follow-up nor two behavioral health interventions; however, that group’s percentage can be calculated by subtracting the total of groups 1-3 from 100%.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)The following patients will be excluded from the respective numerator counts (but will be included in the denominator if they meet the criteria as stated): 1) patients whose behavioral health counseling or family behavioral health interventions included less than 30 minutes of direct contact; 2) patients whose counseling or behavioral health interventions were delivered as part of the well-child care visit.Patients with a current diagnosis of pregnancy will be excluded from the denominator and from the numerator.DSRIP Specific ModificationsNoneAdditional InformationNoneBundle D3 Pediatric Hospital SafetyMeasure Bundle ObjectivesReduce hospital errors, improve effectiveness of staff communication (both internally and with patients and their caregivers), improve medication management, and reduce the risk of health-care associated infections.Target PopulationChildren receiving inpatient careRelated System ComponentsHospitalNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNoMeasures Hospital BasedServicesYesD3-330: Pediatric CLABSIMeasure Description:This measure answers the question: How often is a patient harmed due to central line associated blood stream infections (CLABSIs)?The current 2018 version of the National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol, will serve as the official reference guide for rules around defining/reporting central line associated blood stream infections.One analyses:a) Number of CLABSIs per 1000 central line days (Numerator/Denominator) x 1000b) Total number of blood stream infectionsProcess Data: Observations collected by unit: PICU, CICU, NICU, Hematology-Oncology and all other units.D3-330: Pediatric CLABSIDY7/DY8 Program IDD3-330Measure DetailsSteward: Children’s Hospitals’ Solutions for Patient Safety National Children’s NetworkNQF #: NASource: (Operational Definitions March 2018)Data Source0Required StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionDenominator: Total number of central line days during the time period.For more information regarding blood culture monitoring and data collection within the HEM/ONC units please refer to Appendix A.Denominator InclusionsAll patients are included who are defined as inpatient or under observation at the hospital including one calendar days post discharge (including CLABSIs related to Mucosal Barrier Injuries (MBIs).Denominator ExclusionsInfection must not be present on admission into the hospital as defined by NHSN. For most infections, this means that the infection does not become evident until two calendar days or more after admission, but each infection must be assessed individually.Numerator DescriptionNumber of patients with a CLABSI event, as defined by CDC guidelines. For this measure, distinction is not made between an infection due to CVC/PICC insertion and one due to maintenance practices. Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, only the number of CLABSIs per 1000 central line days. The numerator should be reported as the number of observed infections x1000.Additional InformationAppendix A HEM/ONC patients residing in HEM/ONC units should have additional blood culture data collected and submitted for: Secondary Blood Stream Infections (BSI) and Single Positives - For further clarification on Secondary infections click here for the NHSN guidelines (pages 14-16). - If a positive blood culture doesn’t meet definitions for CLABSI or a Secondary Infection it would be considered a Single Positive Culture. - Calculation Example: Number of CLABSIs (including MBIs) + number of Secondary BSI + Single Positive cultures (all others) = Total number of all positive blood cultures drawn from central lines on a HEM/ONC unitD3-331: Pediatric CAUTIMeasure Description:This measure answers the question: How often are patients harmed by the occurrence of a catheter associated urinary tract infections?The current version (2015) of the National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol will serve as the official reference guide for rules around defining/reporting catheter associated urinary tract infections.D3-331: Pediatric CAUTIDY7/DY8 Program IDD3-331Measure DetailsSteward: Children’s Hospitals’ Solutions for Patient Safety National Children’s NetworkNQF #: NASource: (Operational Definitions March 2018)Data Source0Required StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionEvents per Catheter Day:Denominator: Total number of indwelling urinary catheter days during the time period.Number of urinary tract infections per 1000 urinary catheter days(Numerator/Denominator) x 1000Catheter Days per Patient Days:Denominator: Total number of patient days (excluding NICU)Number of catheter per 1000 patient days (Numerator/Denominator) x 1000Denominator InclusionsAll patients admitted to an inpatient unit are included who are defined as inpatient or under observation at the hospital with an indwelling urinary catheter.Denominator ExclusionsObservation patients admitted to observation units and patients admitted to neonatal intensive care units will be excluded. Infection must not be incubating at the time of the admission into the hospital. For most infections, this means that the infection does not become evident until 48 hours or more after admission, but each infection must be assessed individually. There is no minimum period of time that the catheter must be in place in order for the UTI to be considered catheter associated.Numerator DescriptionEvents per Catheter Day:Numerator: Number of patients contracting an infection, as defined by CDC guidelines x1000.Catheter Days per Patient DaysNumerator: Number of catheter days x1000.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, the numerator should be reported as the number of observed infections x1000.Additional InformationNoneD3-333: Pediatric Surgical site infections (SSI)Measure Description:This measure answers the question: How often is a patient harmed due to surgical site infection following selected surgeries? The current 2018 version of the National Healthcare Safety Network (NHSN) Manual: Patient Safety Component Protocol will serve as the official reference guide for definitions and criteria for reporting surgical site infections. for focus on selected surgeries: In pediatrics, SSI rates tend to be highest among spinal fusion, neurosurgical shunt, and cardiothoracic surgeries.D3-333: Pediatric Surgical site infections (SSI)DY7/DY8 Program IDD3-333Measure DetailsSteward: Children’s Hospitals’ Solutions for Patient Safety National Children’s NetworkNQF #: NASource: (Operational Definitions March 2018)Data Source0Required StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionNumber of designated surgical procedures during the applicable reporting period. Denominator InclusionsAll patients who experience one of the above surgical proceduresDenominator ExclusionsPatients with physician/advanced practice nurse/physician assistant documentation of an active infection at the time of the surgical procedure.-Signs/symptoms of infection can include but not be limited to: fever, redness/tenderness, elevated white blood cell count, positive culture. Numerator DescriptionNumber of SSIs related to designated surgical procedures x1000.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, the numerator should be reported as the number of observed infections x1000.Additional InformationPopulation Definition:The patient population for this measure includes all patients undergoing the included procedures, including inpatient and observational stay patients.Three surgery categories are considered for this measurement: ? Spinal fusion surgeries as defined by NHSN (FUSN). ? Procedures such as growing construct placements and adjustments should be included if a facility routinely uses CPT or ICD-10 codes included in the FUSN category for such procedures.? Neurosurgical shunt surgeries as defined by NHSN (VSHN) ? Procedures such as third ventriculostomy and external ventricular drain placement are included even though technical these are not shunt procedures. ? The CPT code 44055 (correction of malrotation) should be used only if the procedure involves a ventricular shunt.? Cardiothoracic surgeries as defined by NHSN (CARD) ? ICD-10 and CPT codes for each of the above categories are available on the NHSN website in the Supporting Materials section () and SPS sharepoint siteSurgical Site Infection Definitions:Superficial Incisional SSI: Infection occurs within 30 days after the operative procedure AND involves only skin and subcutaneous tissue of the incision AND patient has at least one of the following: a. purulent drainage from the superficial incision.b. organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision.c. superficial incision that is deliberately opened by a surgeon, attending physician or other designee and is culture positive or not cultured and at least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat. A culture-negative finding does not meet this criterion.d. diagnosis of superficial incisional SSI by the surgeon or attending physician or other designee.Deep Incisional SSI: Infection occurs within 90 days AND involves deep soft tissues (e.g., fascial and muscle layers) of the incision AND patient has at least one of the following:a. purulent drainage from the deep incision.b. a deep incision spontaneously dehisces or is deliberately opened by a surgeon, attending physician, or other designee and is culture-positive or not cultured and the patient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. A culture-negative finding does not meet this criterion.c. an abscess or other evidence of infection involving the deep incision is found on direct examination, during invasive procedure, or by histopathological examination or imaging an/Space SSI: Infection occurs within 90 days after the operative procedure AND infection involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedure AND patient has at least one of the following:a. Purulent drainage from a drain that is placed in the organ/spaceb. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/spacec. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during invasive procedure, or by histopathologic examination or imaging testand Meets at least one criterion for a specific organ/space infection site (see )D3-334: Pediatric Adverse Drug EventsMeasure Description:This measure answers the question: How often do is a patient harmed due to drugs given to them? Adverse drug events will be defined per the National Coordinating Council for Medication Error Reporting and Prevention’s Index for Categorizing Medication Errors.D3-334: Pediatric Adverse Drug EventsDY7/DY8 Program IDD3-334Measure DetailsSteward: Children’s Hospitals’ Solutions for Patient Safety National Children’s NetworkNQF #: NASource: Source0Required StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: NAMeasure will be reported as an all-payer rate only.Baseline DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionDenominator: Total number patient days.Number adverse drug events in category E per number patient days per 1000 patients(Numerator/Denominator) * 1000Number of adverse drug events in categories F-I (combined) per number of patient days per 1000 patients(Numerator/Denominator) * 1000Denominator InclusionsAll patients are included who are defined as inpatient or under observation at the hospital.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionNumber of adverse drug events per NCC MERP’s Index for Categorizing Medication Errors x1000.Numerators will be reported as Level E and combined Level F-I as defined below.E = An error occurred that may have contributed to or resulted in temporary harm to the patient and required interventionF = An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalizationG = An error occurred that may have contributed to or resulted in permanent patient harmH = An error occurred that required intervention necessary to sustain lifeI = An error occurred that contributed to or resulted in the patient’s deathNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, the numerator should be reported as the number of observed infections x1000.Additional InformationNoneD3-335: Pediatric Pressure InjuriesMeasure Description:This measure answers the question: How often is a patient harmed due to pressure injury? The National Pressure Ulcer Advisory Panel (NPUAP) will serve as the guide for the defining and staging of pressure injury. The Solutions for Patient Safety (SPS) operational definition will serve as the official guide for the reporting of all hospital acquired pressure injuries detected during hospitalization.D3-335: Pediatric Pressure InjuriesDY7/DY8 Program IDD3-335Measure DetailsSteward: Children’s Hospitals’ Solutions for Patient Safety National Children’s NetworkNQF #: NASource: Source0Required StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: NAMeasure will be reported as an all-payer rate only.Baseline DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionDenominator for both All Harm and Serious Harm: Total number patient days.Denominator InclusionsAll patients are included who are defined as inpatient or under observation at the hospital.Denominator ExclusionsAny patient who has a PI documented upon admission to the hospital, would be excluded because this would be considered a non-facility acquired PI (unless the PI progresses to a stage 3, 4, or unstageable during their hospital stay).All Harm Excludes Stage I pressure injury: Intact skin with a localized area of non-blanch able erythema, which may appear differently in darkly pigmented skin. Presence of blanch able erythema or change sin sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Serious Harm Excludes: Stage 1, 2, Mucosal Injuries, and DTPI.Numerator DescriptionAll Harm Numerator x1000: Number of Mucosal, Stage 2, 3, 4, deep tissue pressure injuries (DTPI), and unstageable pressure injuries as defined below.Serious Harm Numerator: Number of Stage 3, 4, and unstageable pressure injuries as defined below.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, the numerator should be reported as the number of observed infections x1000.Additional InformationNoneBundle D4 Pediatric Chronic Disease Management: AsthmaMeasure Bundle ObjectivesDevelop and implement chronic disease management interventions that are geared toward improving management of asthma to improve patient health outcomes and quality of life and reduce unnecessary acute and emergency care utilization.Target PopulationDSRIP attributed children up to age 21 at the beginning of the measurement period with a diagnosis of Asthma (ICD-10 J45) that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement periodInclude children that meet any of the following criteria: 1. Any prior hospitalization with asthma as primary or secondary diagnosis2. One or more asthma related prescriptions3. Other qualifying events after the fifth birthday at time of event: a. One or more prior ambulatory visits with asthma as the primary diagnosis OR b. Two or more ambulatory visits with asthma as any diagnosis, OR d. Two or more ambulatory visits with a diagnosis of bronchitisFor eligibility purposes, asthma-related medicine refers to long acting beta agonist (alone or in combination) or inhaled corticosteroid (alone or in combination), anti- asthmatic combinations, methylxanthines (alone or in combination), and/or mast cell stabilizers. Use current NCQA list. Exclude medications in the following 2 categories: leukotriene modifiers, short-acting inhaled beta-2 angonistsRelated System ComponentsOutpatient primary care, relevant outpatient specialty care, ED, inpatientNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesD4-139: Asthma Admission Rate (PDI14) Measure Description:Admissions with a principal diagnosis of asthma per population, ages 2 through 17 years. Excludes cases with a diagnosis code for cystic fibrosis and anomalies of the respiratory system, obstetric admissions, and transfers from other institutions.D4-139: Asthma Admission Rate (PDI14)DY7/DY8 Program IDD4-139Measure DetailsSteward: AHRQNQF #: 0728Source: AHRQ: SourceClaimsRequired StatusRequiredMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DescriptionChildren ages 2 through 17 years old. Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionDischarges, for patients ages 2 through 17 years, with a principal ICD-10-CM diagnosis code for asthmaNumerator Inclusions (Performance Met)Asthma diagnosis codes: (ACSASTD):J4521, Mild intermittent asthma with (acute) exacerbationJ4552, Severe persistent asthma with status asthmaticusJ4522, Mild intermittent asthma with status asthmaticusJ45901, Unspecified asthma with (acute) exacerbationJ4531, Mild persistent asthma with (acute) exacerbationJ45902, Unspecified asthma with status asthmaticusJ4532, Mild persistent asthma with status asthmaticusJ45990, Exercise induced bronchospasmJ4541 ,Moderate persistent asthma with (acute) exacerbationJ45991, Cough variant asthmaJ4542, Moderate persistent asthma with status asthmaticusJ45998, Other asthmaJ4551, Severe persistent asthma with (acute) exacerbation Numerator Exclusions (Performance Not Met)Exclude cases:? with any-listed ICD-10-CM diagnosis codes for cystic fibrosis and anomalies of the respiratory system (RESPAN*)? transfer from a hospital (different facility) (Appendix J)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)? transfer from another health care facility? MDC 14 (pregnancy, childbirth, and puerperium)APPENDIX J: Admission Codes for Transfers- 02 Another hospital- 03 Another facility, including long term carePointoforiginub04 codes:- 04 Transfer from a hospital- 05 Transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)- 06 Transfer from another health care facilityIf Admission Type is newborn (ATYPE=4), codes are as follows:- 05 Born inside this hospital- 06 Born outside of this hospitalCystic fibrosis and anomalies of the respiratory system diagnosis codes: (RESPAN):E840, Cystic fibrosis with pulmonary manifestationsQ320. Congenital tracheomalaciaE8411, Meconium ileus in cystic fibrosisQ321, Other congenital malformations of tracheaE8419, Cystic fibrosis with other intestinal manifestationsQ322, Congenital bronchomalaciaE848, Cystic fibrosis with other manifestationsQ323, Congenital stenosis of bronchusE849, Cystic fibrosis, unspecifiedQ324, Other congenital malformations of bronchusJ8483, Surfactant mutations of the lungQ330, Congenital cystic lungJ84841, Neuroendocrine cell hyperplasia of infancyQ331, Accessory lobe of lungJ84842, Pulmonary interstitial glycogenosisQ332. Sequestration of lungJ84843, Alveolar capillary dysplasia with vein misalignmentQ333, Agenesis of lungJ84848, Other interstitial lung diseases of childhoodQ334, Congenital bronchiectasisP270, Wilson-Mikity syndromeQ335, Ectopic tissue in lungP271, Bronchopulmonary dysplasia originating in the perinatal periodQ336, Congenital hypoplasia and dysplasia of lungP278, Other chronic respiratory diseases originating in the perinatal periodQ338, Other congenital malformations of lungP279, Unspecified chronic respiratory disease originating in the perinatal periodQ339, Congenital malformation of lung, unspecifiedQ2545, Double aortic archQ340, Anomaly of pleuraQ2547, Right aortic archQ341, Congenital cyst of mediastinumQ2548, Anomalous origin of subclavian arteryQ348, Other specified congenital malformations of respiratory systemQ311, Congenital subglottic stenosisQ349, Congenital malformation of respiratory system, unspecifiedQ312, Laryngeal hypoplasiaQ390, Atresia of esophagus without fistulaQ313, LaryngoceleQ391, Atresia of esophagus with tracheo-esophageal fistulaQ315, Congenital laryngomalaciaQ392, Congenital tracheo-esophageal fistula without atresiaQ318, Other congenital malformations of larynxQ393, Congenital stenosis and stricture of esophagusQ319, Congenital malformation of larynx, unspecifiedQ394, Esophageal webQ893, Situs inversusDSRIP Specific ModificationsSpecified that denominator is the DSRIP Attributed Target Population. Admissions should be limited to individuals from the DSRIP attributed target population who are 2-17 years old.Additional InformationSee measure source for included and excluded valuesD4-353: Proportion of Children with ED Visits for Asthma with Evidence of Primary Care Connection Before the ED VisitMeasure Description:This measure describes the incidence rate of emergency department visits for children ages 2 to 21 who are being managed for identifiable asthma. This measure characterizes care that precedes Emergency Department visits for children ages 2- 21 who can be identified as having asthma, using the specified definitions. The developers sought to identify children with ongoing asthma who should be able to be identified by their healthcare providers and/or healthcare plans as having asthma. The operational definition of an identifiable asthmatic is a child who has utilized healthcare services that suggest the healthcare system has enough information to conclude that the child has an asthma diagnosis that requires ongoing care. Specifically, this measure identifies the use of primary care services and medications prior to ED visits and/or hospitalizations for children with asthma.D4-353: Proportion of Children with ED Visits for Asthma with Evidence of Primary Care Connection Before the ED VisitDY7/DY8 Program IDD4-353Measure DetailsSteward: University Hospitals Cleveland Medical CenterNQF #: 3170Source: SourceClaimsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll first ED visits and/or hospitalizations, in which asthma was a primary or secondary diagnosis in children age 2-21 who meet criteria for being managed for identifiable asthma in the assessment periodDenominator InclusionsThe assessment period includes the full year before the reporting year and each full calendar month before the month in which the ED visit (which is referred to as the reporting month). ? Any prior hospitalization with asthma as primary or secondary diagnosis: ? Other qualifying events after the fifth birthday at time of event: a.One or more prior ambulatory visits with asthma as the primary diagnosis (this criterion implies an asthma ED visit in the reporting month): OR b.Two or more ambulatory visits with asthma as a diagnosis, OR c.One ambulatory visit with asthma as a diagnosis AND at least One asthma related prescription, OR d.Two or more ambulatory visits with a diagnosis of bronchitis? Other qualifying events, any age: a.Three or more ambulatory visits with diagnosis of asthma or bronchitis, OR b.Two or more ambulatory visits with a diagnosis of asthma and/or bronchitis AND one or more asthma related prescriptionsFor eligibility purposes, asthma-related medicine refers to long acting beta agonist (alone or in combination) or inhaledcorticosteroid (alone or in combination), anti- asthmatic combinations, methylxanthines (alone or in combination), and/or mast cellstabilizers. Hospitalization CPT Codes: 99238 , 99239, 99221, 99222, 99223, 99356, 99357, 99231, 99232, 99233, 99234, 99235, 99236, 99218, 99219, 99220 Hospitalization Revenue Codes: 0110, 0111, 0112, 0113, 0114, 0117, 0119, 0120, 0121, 0122, 0123, 0124, 0127, 0129, 0130, 0131, 0132, 0133, 0134, 0137, 0139, 0150, 0151, 0152, 0153, 0154, 0157, 0159, 0200, 0201, 0202, 0203, 0204, 0206 Office Visit CPT Codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215 Previous ED Visit CPT Codes: 99281, 99282, 99283, 99284, 99285 Previous ED Visit Revenue Codes: 0450 Emergency Room 0451 Emergency Room: EM/EMTALA 0452 Emergency Room: ER/Beyond EMTALA 0456 Emergency Room: Urgent Care 0459 Emergency Room: Other Emergency Room 450 Emergency Room 451 Emergency Room: EM/EMTALA 452 Emergency Room: ER/Beyond EMTALA 456 Emergency Room: Urgent Care 459 Emergency Room: Other Emergency Room 0981 Professional Fees (096x) Emergency Room 981 Professional Fees emergency room ICD-10 Codes Diagnosis of Asthma (Inclusions): J45.20, J45.22, J45.21, J45.20, J45.22, J45.21, J45.990, J45.991, J45.909, J45.998, J45.902, J45.901, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.909, J42 ICD-10 Codes Diagosis of Asthma (Exclusions): J44.9, E84.9, E84.11, E84.0, E84.19, E84.8, J43.9, J43.9, J44.9, J44.0, J44.1, E84.1, J43.8, J43.0, J43.1, J43.2, J98.3, J68.4, J98.2, J98.2, P25.0 Filled prescriptions for asthma related medications: Use curreent NCQA list. Exlude medications in the following 2 categories: leukotriene modifiers, short-acting inhaled beta-2 angonistsDenominator ExclusionsChildren with concurrent or pre-existing: Chronic Obstructive Pulmonary Disease (COPD) diagnosis; Cystic Fibrosis diagnosis; Emphysema diagnosisChildren who do not meet the denominator criteria.Numerator DescriptionEvidence of connection to the primary care medical system prior to first ED visit and/or hospitalization that has a primary or secondary diagnosis of asthma among children whom our specifications identify with asthma.Numerator Inclusions (Performance Met)Evidence of connection to the primary care medical system prior to first ED visit and/or hospitalization that has a primary or secondary diagnosis of asthma among children whom our specifications identify with asthma, includes the following: (A) Visit(s) to a primary care clinician with a primary or secondary diagnosis of asthma that occurred within 6 months prior to an ED visit/hospital admission (but not on the day of the ED visit/admission, (B) Have at least one fill of a short acting beta agonist within 12 months prior to the ED visit/hospital admission and (C) Have at least one fill of an asthma controller medication within 6 months prior to the ED visit/hospital admission. This numerator excludes events occurring in patients who meet numerator but not denominator criteriaNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsRemoved step related to identifying eligibility based on plan enrollment. Clarified that the numerator is all children from the denominator who meet one or more of numerator criteria A - C. Removed instructions related to supplemental data collection (steps 9 - 10 in the source specifications)Additional InformationStep 1: Assess eligibility. For any given reporting month, assess eligibility on 2 criteria. Eligible children are those that meet both of the following: A. Identify the assessment period. We classify children as having identifiable asthma by evaluating services used during what we call the assessment period. The analysis period consists of the 2 year look back period plus all prior months in the Reporting Year. In other words if calendar year 2012 is the Reporting Year, the look back period would include calendar years 2010 and 2011. When looking for events in January 2011, the assessment period would include only CY 2009 and CY 2010. For February 2011, the assessment period would include CY 2010, CY 2011 and January 2012, and so on until for December the look back period would include CY 2010, CY 2011 and January-November, 2012. B. Analyze the data month by month in chronological order. Evaluate for the presence of identifiable asthma if any of the criteria described in a, b, or c below are satisfied, (along with an ED visit with the primary or secondary diagnosis of asthma): a. Any prior hospitalization with asthma as primary or secondary diagnosis b. Qualifying events after the fifth birthday at time of event: i.One or more prior ambulatory visits with asthma as the primary diagnosis OR ii.Two or more ambulatory visits with asthma as a diagnosis, OR iii.One ambulatory visit with asthma as a diagnosis AND at least One asthma related prescription, OR iv.Two or more ambulatory visits with a diagnosis of bronchitis c. Qualifying events, any age: i.Three or more ambulatory visits with diagnosis of asthma or bronchitis, OR ii.Two or more ambulatory visits with a diagnosis of asthma AND/OR iii.Bronchitis AND one or more asthma related prescriptionsStep 2: Look for any qualifying events (eligible events) using the criteria for hospitalization and/or ED visits.For months in which each child is found to be eligible using both the criteria for identifiable asthma and the continuous enrollment criteria (Step 1), identify whether that is the first eligible event for the child in the reporting year. If so, include in the denominator.Step 3: The denominator is the number of children with identifiable asthma who had qualifying events. Use the first such event for each child when assessing each numerator.Step 4: Identify Numerator A. Numerator A is the number of eligible children with an ED visit and/or hospitalization who had a visit with primary care doctor with primary or secondary diagnosis of asthma within 6 months prior to the ED visit and/or hospitalization(and not including the day of the ED visit/admission).Step 5: Identify Numerator B. Numerator B is the number of eligible children with an ED visit and/or hospitalization who were presribed a short acting beta agonist within the prior 12 months before the ED visit and/or hospitalization (and not including the day of the ED visit/admission).Step 6: Identify Numerator C. Numerator C is the number of eligible children with an ED visit and/or hospitalization who were prescribed a controller medication prescription within the prior 6 months before the ED visit and/or hospitalization (and not including the day of the ED visit/admission). NOTE: For DSRIP reporting purposes, the numerator is the unduplicated number of children identified in Numerator A - C. Children who are identified in multiple numerator criteria will count once towards the numerator. Hospitalization CPT Codes: 99238 , 99239, 99221, 99222, 99223, 99356, 99357, 99231, 99232, 99233, 99234, 99235, 99236, 99218, 99219, 99220 Hospitalization Revenue Codes: 0110, 0111, 0112, 0113, 0114, 0117, 0119, 0120, 0121, 0122, 0123, 0124, 0127, 0129, 0130, 0131, 0132, 0133, 0134, 0137, 0139, 0150, 0151, 0152, 0153, 0154, 0157, 0159, 0200, 0201, 0202, 0203, 0204, 0206 Office Visit CPT Codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215 Previous ED Visit CPT Codes: 99281, 99282, 99283, 99284, 99285 Previous ED Visit Revenue Codes: 0450 Emergency Room 0451 Emergency Room: EM/EMTALA 0452 Emergency Room: ER/Beyond EMTALA 0456 Emergency Room: Urgent Care 0459 Emergency Room: Other Emergency Room 450 Emergency Room 451 Emergency Room: EM/EMTALA 452 Emergency Room: ER/Beyond EMTALA 456 Emergency Room: Urgent Care 459 Emergency Room: Other Emergency Room 0981 Professional Fees (096x) Emergency Room 981 Professional Fees emergency room ICD-10 Codes Diagnosis of Asthma (Inclusions): J45.20, J45.22, J45.21, J45.20, J45.22, J45.21, J44.9, J44.0, J44.1, J45.990, J45.991, J45.909, J45.998, J45.902, J45.901, J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.909, J42 ICD-10 Codes Diagosis of Asthma (Exclusions): J44.9, E84.9, E84.11, E84.0, E84.19, E84.8, J43.9, J43.9, J44.9, J44.0, J44.1, E84.1, J43.8, J43.0, J43.1, J43.2, J98.3, J68.4, J98.2, J98.2, P25.0 Filled prescriptions for asthma related medications: Use curreent NCQA list. Exlude medications in the following 2 categories: leukotriene modifiers, short-acting inhaled beta-2 angonistsD4-375: Asthma: Pharmacologic Therapy for Persistent Asthma (Rate 3 only)Measure Description:Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medicationD4-375: Asthma: Pharmacologic Therapy for Persistent Asthma (Rate 3 only)DY7/DY8 Program IDD4-375Measure DetailsSteward: The American Academy of Asthma Allergy and ImmunologyNQF #: 0047Source: SourceClaimsRequired StatusRequiredMeasure 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 5 years and older with a diagnosis of persistent asthmaDenominator InclusionsDenominator Instructions: Documentation of persistent asthma must be present. One method of identifying persistent asthma is, at a minimum, daily use of short-acting bronchodilators Denominator Criteria (Eligible Cases):Patients aged ≥ 5 years on date of encounterANDDiagnosis for asthma (ICD-10-CM): J45.30, J45.31, J45.32, J45.40, J45.41, J45.42, J45.50,J45.51, J45.52, J45.901, J45.902, J45.909, J45.990, J45.991, J45.998ANDPatient encounter during the reporting period (CPT): 99201, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350ANDPersistent Asthma (mild, moderate or severe) (1038F)Note: Providers should limit office visit/E&M codes 99201 -99205 and 99211 - 99215 sets to primary care and related outpatient specialty care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.Denominator ExclusionsDocumentation of patient reason(s) for not prescribing inhaled corticosteroids or alternative long-term control medication (eg, patient declined, other patient reason) (4140F with 2P)Numerator DescriptionPatients who were prescribed long-term control medicationNumerator Inclusions (Performance Met)Inhaled corticosteroids prescribed (4140F)ORAlternative long-term control medication prescribed (4144F)Numerator Exclusions (Performance Not Met)Inhaled corticosteroids or alternative long-term control medication not prescribed, reason not otherwise specified (4140F with 8P)DSRIP Specific ModificationsThis measure is specified with 3 performance rates; 1) Patients prescribed inhaled corticosteroids (ICS) as their long-term control medication, 2) Patients prescribed alternative long-term control medications (non-ICS), and 3) Total patients prescribed long-term control medication . For DSRIP Reporting purposes, providers will report rate 3 only (total patients prescribed long-term control medications)Additional InformationICD-10-CM diagnosis codes, CPT codes, QDC code and patient demographics are used to identify patients who are included in the measure’s denominator. The listed numerator options are used to reportthe numerator of the measure. Definition:Long-Term Control Medication Includes: Patients prescribed inhaled corticosteroids (the preferred long-term control medication at any step of asthma pharmacological therapy)OR Patients prescribed alternative long-term control medications (inhaled steroid combinations, antiasthmatic combinations, antibody inhibitor, leukotriene modifiers, mast cell stabilizers, methylxanthines) OR an acceptable alternative long-term control medication at one or more visits in the 12-month period OR patient already taking inhaled corticosteroid OR an acceptable alternative long-term control medication as documented in current medication listBundle D5 Pediatric Chronic Disease Management: DiabetesMeasure Bundle ObjectivesDevelop and implement diabetes management interventions that improve patient health outcomes and quality of life, prevent onset or progression of comorbidities, and reduce unnecessary acute and emergency care utilization.Target PopulationDSRIP attributed children (0 - 21) with a diagnosis of type 1 or type 2 diabetes (Patients with a principal ICD-10-CM diagnosis code for Type 1 DM (E10.1-E10.9) or with a principal ICD-10-CM diagnosis code for Type 2 DM(E11.0-E11.9) that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement periodRelated System ComponentsOutpatient primary care, relevant outpatient specialty care, ED, inpatientNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesD5-211: 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 activityD5-211: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ AdolescentsDY7/DY8 Program IDD5-211Measure DetailsSteward: NCQANQF #: 0024Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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%- Counseling for Nutrition: DY7 goal is 70.88% and DY8 goal of 71.74%- Counseling for Physical Activity: DY7 goal is 63.47% and DY8 goal of 64.28%Denominator 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: $OutpatientVisitsNote: Providers should limit office visit value set, and face-to-face-interaction value sets to primary care and related outpatient specialty care. Providers may limit by location of service, physician or clinic type, but may not limit by criteria related to purpose of encounter.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: "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)"D5-406: Diabetes Short-term Complications Admission Rate (PDI 15)Measure Description:Admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) per 100,000 population, ages 6 through 17 years. Excludes obstetric admissions and transfers from other institutions.D5-406: Diabetes Short-term Complications Admission Rate (PDI 15)DY7/DY8 Program IDD5-406Measure DetailsSteward: AHRQNQF #: NASource: AHRQ: SourceClaimsRequired StatusRequiredMeasure ClassificationType: Population Based 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 with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 DSRIP Attributed Target PopulationDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionDischarges, for patients ages 6 through 17 years, with a principal ICD-10-CM diagnosis code for diabetes short-term complications (ketoacidosis, hyperosmolarity, or coma)Numerator Inclusions (Performance Met)Diabetes short-term complications diagnosis codes: (ACDIASD)E1010, Type 1 diabetes mellitus with ketoacidosis without comaE1100, Type 2 diabetes mellitus with hyperosmolarity withoutnonketotic hyperglycemic-hyperosmolar coma (NKHHC)E1011, Type 1 diabetes mellitus with ketoacidosis with comaE1101, Type 2 diabetes mellitus with hyperosmolarity with comaE10641, Type 1 diabetes mellitus with hypoglycemia with comaE11641, Type 2 diabetes mellitus with hypoglycemia with comaNumerator Exclusions (Performance Not Met)Exclude cases:? transfer from a hospital (different facility)? transfer from a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF)? transfer from another health care facility (Appendix J)? MDC 14 (pregnancy, childbirth, and puerperium)DSRIP Specific ModificationsSpecified that denominator is the DSRIP Attributed Target Population. Admissions should be limited to individuals from the DSRIP attributed target population.Additional InformationSee measure source for included and excluded valuesD5-T07: Innovative Measure: Diabetes Outpatient Care Management (Care Coordination)Measure Description:Two rates are reported: Rate 1: ED visits for Type 1 and Type 2 Diabetes, Rate 2: Admissions for Type 1 and Type 2 DiabetesD5-T07: Innovative Measure: Diabetes Outpatient Care Management (Care Coordination)DY7/DY8 Program IDD5-T07Measure DetailsSteward: Children's Hospital Association of TexasNQF #: NASource: NAData SourceDenominator- Outpatient/ClinicNumerator Rate 1- Emergency Room (ER) and Urgent Care (UC)Numerator Rate 2- Inpatient and/or observation status admissionsData may be abstracted electronically or manually from organizational EHR or administrative data setRequired StatusOptional Innovative MeasureMeasure ClassificationType: InnovativeMeasure Parts: 2Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit 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 DescriptionRate 1.a: - Rate of Emergency Department (ED) or Urgent Care (UC) visits for established patients with Type 1 Diabetes Mellitus (DM).Rate 1.b: - Rate of Emergency Department (ED) or Urgent Care (UC) visits for established patients with Type 2 Diabetes Mellitus (DM).Rate 2.a: - Primary Diabetes outpatients in practice for over 1 year and seen 2 or more times in the last measurement period with a principal diagnosis of Type 1 DM.Rate 2.b: - Primary Diabetes outpatients in practice for over 1 year and seen 2 or more times in the last measurement period with a principal diagnosis of Type 2 DM.Denominator InclusionsEstablished Diabetes patients (>1 year from initial diagnosis) under 21 years of age ANDRate 1.a: - Patients with a principal ICD-10-CM diagnosis code for Type 1 DM (E10.1-E10.9) Rate 1.b: - Patients with a principal ICD-10-CM diagnosis code for Type 2 DM (E11.0-E11.9).Rate 2.a: - Patients with a principal ICD-10-CM diagnosis code for Type 1 DM (E10.1-E10.9).Rate 2.b: - Patients with a principal ICD-10-CM diagnosis code for Type 2 DM (E11.0-E11.9).Denominator ExclusionsRate 1.a: - Exclude diabetes associated with other conditions, such as cystic fibrosis, steroid-induced, neonatal, obstetric, MODY or transplant-induced.- Exclude MDC 14 (pregnancy, childbirth, puerperium).- Exclude new onset diabetes patients (<1 year from initial diagnosis).Rate 1.b: - Exclude diabetes associated with other conditions, such as cystic fibrosis, steroid-induced, neonatal, obstetric, MODY or transplant-induced.- Exclude patients with pre-diabetes (R73.03).- Exclude MDC 14 (pregnancy, childbirth, puerperium).- Exclude new onset diabetes patients (<1 year from initial diagnosis).Rate 2.a: - Exclude diabetes associated with other conditions, such as cystic fibrosis, steroid-induced, neonatal, obstetric, MODY or transplant-induced.- Exclude MDC 14 (pregnancy, childbirth, puerperium).- Exclude new onset diabetes patients (<1 year from initial diagnosis).Rate 2.b: - Exclude diabetes associated with other conditions, such as cystic fibrosis, steroid-induced, neonatal, obstetric, MODY or transplant-induced.- Exclude patients with pre-diabetes (R73.03).- Exclude MDC 14 (pregnancy, childbirth, puerperium).- Exclude new onset diabetes patients (<1 year from initial diagnosis).Numerator DescriptionRate 1.a: - Number of patients in denominator seen in Urgent Care or the Emergency Room for Diabetes-related causes (hyperglycemia, DKA, hypoglycemia).Rate 1.b:- Number of patients in denominator seen in Urgent Care or the Emergency Room for Diabetes-related causes (hyperglycemia, DKA, hypoglycemia).Rate 2.a: - Number of patients in denominator admitted inpatient or observation status for Diabetes-related causes (hyperglycemia, DKA, hypoglycemia).Rate 2.b: - Number of patients in denominator admitted inpatient or observation status for Diabetes-related causes (hyperglycemia, DKA, hypoglycemia).Numerator Inclusions (Performance Met)Rate 1.a: - Patients from the denominator seen in the UC or ED with a diagnosis code for hyperglycemia (E10.65, R73.9), DKA (E10.1, E10.10, E10.11), hypoglycemia (E10.64, E10.641, E10.649)- Include Urgent Care(s) or Emergency Room(s) as part of the same organization/healthcare system as the outpatient clinic.Rate 1.b: - Patients from the denominator seen in the UC or ED with a diagnosis code for hyperglycemia (E11.65, R73.9), DKA (E11.1, E11.10, E11.11), hypoglycemia (E11.64, E11.641, E11.649)- Include Urgent Care(s) or Emergency Room(s) as part of the same organization/healthcare system as the outpatient clinic.Rate 2.a: - Patients from the denominator admitted with a diagnosis code for hyperglycemia (E10.65, R73.9), DKA (E10.1, E10.10, E10.11), hypoglycemia (E10.64, E10.641, E10.649)- Include inpatient as part of the same organization/healthcare system as the outpatient clinic.Rate 2.b: - Patients from the denominator admitted with a diagnosis code for hyperglycemia (E11.65, R73.9), DKA (E11.1, E11.10, E11.11), hypoglycemia (E11.64, E11.641, E11.649)- Include inpatient as part of the same organization/healthcare system as the outpatient clinic.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationMeasure specified by CHAT as four parts, stratifying each rate by DM Type 1 and DM Type 2. For DSRIP reporting purposes, Rate 1.a and Rate 1.b should should be added together to report a single numerator and a single denominator, and Rate 2.a and Rate 2.b should be added together to report a single numerator and a single denominator. Providers should report the Type 1 and Type 2 stratifications for each rate qualitatively.Bundle E1 Improved Maternal CareMeasure Bundle ObjectivesImprove maternal health outcomes by implementing evidence-based practices to provide pre-conception, prenatal and postpartum care including early detection and management of comorbidities like hypertension, diabetes, and depression.Target PopulationIndividuals with one or more prenatal or postnatal visit to the performing provider system during the measurement year or the year prior to the measurement year per measure specificationsRelated System ComponentsOutpatient Specialty Care (OB)NOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoE1-193: Contraceptive Care – Postpartum Women Ages 15–44 Measure Description:Among women ages 15 through 44 who had a live birth, the percentage that is provided: Rate 1) A most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately (i.e., injectables, oral pills, patch, ring, or diaphragm) effective method of contraception within 60 days of delivery, and Rate 2) A long-acting reversible method of contraception (LARC) within 60 days of delivery.In total, two rates will be reported for the measure: - Ages 15 to 44: Most or moderately effective contraception – 60 days- Ages 15 to 44: LARC – 60 daysE1-193: Contraceptive Care – Postpartum Women Ages 15–44DY7/DY8 Program IDE1-193Measure DetailsSteward: US Office of Population AffairsNQF #: 2902Source: CMS Adult Core SetData SourceClaimsRequired StatusOptional with additional points if selectedMeasure ClassificationType: ProcessMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: PositiveUnit of Measurement for Payer TypeUnit: EncounterMeasure 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 ages 15 through 44 who had a live birth in a 12-month measurement year.Denominator InclusionsWomen ages 15 through 44 years as of the end of the measurment year who had a live birth in the measurement year.Women will be excluded from the denominator if they did not have an opportunity to receive contraception in the postpartum period (defined as within 60 days of delivery). Follow the steps below to identify the eligible populationStep 1:Identify live births and deliveries by using the codes below: Table CCP-A Codes to Identify a Live Birth or Delivery Value set: ICD-10-PCS: 10D00Z0, 10D00Z1, 10D00Z2, 10D07Z3, 10D07Z4, 10D07Z5, 10D07Z6, 10D07Z7, 10D07Z8, 10E0XZZCPT: 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614,59618, 59620, 59622Denominator ExclusionsStep 2:Exclude deliveries that did not end in a live birth using the codes below:Table CCP-B:Codes to Identify Deliveries that did not end in a live birthICD-10-CPS: O00-O08, O36.4XX0, O36.4XX1, O36.4XX2, O36.4XX3, O36.4XX4, O36.4XX5, O36.4XX9CPT: 59821, 59830, 59120, 59121, 59130, 59135, 59136, 59140, 59840, 59841, 59850, 59851, 59852, 59855, 59856, 59857Step 3Exclude deliveries that occurred during the last 60 days of the measurement year. These deliveries should be excluded from the denominator because there may not have been an opportunity to provide the woman with contraception during the postpartum period. ACOG recommends having a postpartum visit by 6 weeks.Numerator DescriptionRate 1: The eligible population that was provided a most or moderately effective method of contraception within 60 days of delivery. Rate 2: Women ages 15 through 44 who had a live birth and were provided a long-acting reversible method of contraception (LARC) within 60 days of delivery.Numerator Inclusions (Performance Met)Rate 1:Step 4Define the numerator by identifying women who were provided a most (sterilization, IUD, implant) or moderately (injection, oral pills, patch, ring, or diaphragm) effective method of contraception in the measurement year using codes from Table CCP-C: Table CCP-C Codes to Identify Provision of Most or Moderately Effective Contraceptive Methods: ICD-10-CM: Z30.2, Z98.51, Z30.014, Z30.430, Z30.433, Z30.431, Z97.5, T83.31XA, T83.31XD, T83.31XS, T83.31XA, T83.32XD, T83.32XS, T83.39XA, T83.39AD, T83.39XS, Z30.017, Z30.46, Z30.011, Z30.41, Z30.016, Z30.45, Z30.015, Z30.44 ICD-10-PCS: 0U574ZZ, 0U578ZZ, 0UL74CZ, 0UL74DZ, 0UL74ZZ, 0UL78DZ, 0UL78ZZ, 0UH97HZ, 0UH98HZ, 0UHC7HZ, 0UHC8HZ CPT: 58600, 58605, 58615, 58611, 58670, 58671, 58565, 58300, 11981, 11983, 57170 HCPCS: A4264, J7297, J7298, J7300, J7301, J7302, S4989, Q0090, S4981, J7306, J7307, J1050, S4993, J7304, J7303, A4261, A4266 NDC: Codes for Hormonal Implant, Injectable (1-month/3-months), Oral Contraceptive Pills, Patch, Vaginal Ring, DiaphragmStep 5:Adjust for LARC removals and re-insertions. The LARC methods can be removed at the woman’s request so adjustments must be made to reflect this. Use the following codes in Table CCP-D to identify women who had their IUD or implant removed at any point during the measurement year: Table CCP-D Codes Used to Identify Removal/Discontinued Use of LARC ICD-10-CM: Z30.432 ICD-10-PCS: 0UPD7HZ, 0UPD8HZ CPT: 58301, 11976, 11982Check to see if they had an IUD or implant inserted or reinserted on the same or a subsequent date using the following codes in Table CCP-E: Table CCP-E Codes to Identify Use of LARC: ICD-10-CM: Z30.014, Z30.430, Z30.433, Z30.431, Z97.5, T83.39XA, T83.31XD, T83.31XS, T83.31XA, T83.32XD, T83.32XS, T83.39XA, T83.39AD, T83.39XS, Z30.017, Z30.46 ICD-10-PCS: 0UH97HZ, 0UH98HZ, 0UHC7HZ, 0UHC8HZ CPT: 58300, 11981, 11983 HCPS: J7297, J7298, J7300, J7301, J7302, S4989, Q0090, S4981, J7306, J7307 NDC: Codes for IUD/IUSIf there is no code indicating reinsertion, use the codes in Table CCP-C, minus the Intrauterine Device (IUD/IUS) and Hormonal Implant codes to determine whether a woman was provided another most or moderately effective method in the 30 days prior to the removal (since a woman may receive a prescription for another method prior to the removal). Additionally, use all the codes in Table CCP-C to look for a subsequent most or moderately effective method in the period after the LARC removal until the end of the measurement year. If there is no code for reinsertion or provision of another most or moderately effective method, consider them as a non-user. Rate 2:Step 4Define the numerator by identifying women who were provided a LARC in the measurement year. To do this, use the codes in Table CCP-E.Step 5Adjust for LARC removals and re-insertions. The LARC methods can be removed at the woman’s request so adjustments must be made to reflect this. Use the codes in Table CCP-D to identify women who had their IUD or implant removed at any point during the measurement year. Check to see if they had an IUD or implant inserted or reinserted on the same or a subsequent date through the end of the measurement year using Table CCP-E. If there is no code for reinsertion or provision of another most or moderately effective method, consider them as a non-user of LARC.Step 6Determine the date that the LARC method was provided to identify women that were provided LARC within 60 days of delivery.Numerator Exclusions (Performance Not Met)None listed by measure stewardDSRIP 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 a single rate for women age 15 - 44, instead of two separate age-stratified rates for women age 15 - 20 and 21 - 44 as specified in the CMS Child Core Set and Adult Core SetAdditional InformationReferenced value sets are availabe in the 2017 CMS Child Non HEDIS Value Set Directory: ? Some women may have more than one delivery in the measurement year; the measure is designed to identify unique live births (defined as those that occur >180 days apart) rather than women who had a live birth.? Women with a live birth occurring after October 31 are excluded from the denominator because there may not have been an opportunity to provide the woman with contraception in the postpartum period (defined as within 60 days of delivery).? When calculating the number of days postpartum for the numerator, consider the date of delivery to be day 0. For instance, review all claims through December 27, 2016 for the 60 day postpartum rates. DEFINITIONS:Provision of a most effective method of contraception: Provision of female sterilization, contraceptive implants, or intrauterine devices or systems (IUD/IUS).Provision of a moderately effective method of contraception: Provision of injectables, oral pills, patch, ring, or diaphragm.Provision of a long-acting reversible method of contraception (LARC): Provision of contraceptive implants, intrauterine devices or systems (IUD/IUS).E1-232: Timeliness of PrenatalMeasure Description:The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal care:Rate 1: Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization. E1-232: Timeliness of Prenatal CareDY7/DY8 Program IDE1-232Measure DetailsSteward: NCQANQF #: 1517Source: HEDIS 2017 CMS Child Core Set of Measures: Data SourceE.H.R.Required StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: Timeliness of Prenatal Care: 0.91Postpartum Care: 0.7361MPL: Timeliness of Prenatal Care: 0.7421Postpartum Care: 0.5547National Quality Compass 2016 - All LOBs: Average (90th and 25th percentiles)Directionality: PositiveUnit of Measurement for Payer TypeUnit: IndividualsMedicaid only rateBaseline 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 is 87.56% and DY8 goal is 87.90%.Denominator DescriptionDeliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year.Denominator InclusionsEligible Population: Delivered a live birth on or between November 6 of the year prior to the measurement year and November 5 of the measurement year. Include women who delivered in any setting.Multiple births. Women who had two separate deliveries (different dates of service) between November 6 of the year prior to the measurement year and November 5 of the measurement year should be counted twice. Women who had multiple live births during one pregnancy should be counted once in the measure.Follow the steps below to identify the eligible population, which is the denominator for the rate:Step 1Identify deliveries. Identify all women with a delivery (Deliveries Value Set) on or between November 6 of the year prior to the measurement year and November 5 of the measurement year.Step 2Exclude non-live births (Non-live Births Value Set).Denominator ExclusionsNon-live birthsNumerator DescriptionThe percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.Numerator Inclusions (Performance Met)Prenatal care visit to an OB/GYN practitioner or other prenatal care practitioner or PCP. For visits to a PCP a diagnosis of pregnancy must be present. Documentation in the medical record must include a note indicating the date when the prenatal care visit occurred, and evidence of one of the following:? A basic physical obstetrical examination that includes auscultation for fetal heart tone, or pelvic exam with obstetric observations, or measurement of fundus height (a standardized prenatal flow sheet may be used).? Evidence that a prenatal care procedure was performed, such as: - Screening test in the form of an obstetric panel (must include all of the following: hematocrit, differential WBC count, platelet count, hepatitis B surface antigen, rubella antibody, syphilis test, RBC antibody screen, Rh and ABO blood typing), or - TORCH antibody panel alone, or - A rubella antibody test/titer with an Rh incompatibility (ABO/Rh) blood typing, or - Echography of a pregnant uterus - Documentation of LMP or EDD in conjunction with either of the following:? Prenatal risk assessment and counseling/education? Complete obstetrical historyNumerator Exclusions (Performance Not Met)None listed by measure stewardDSRIP Specific ModificationsMeasure is based on the 2017 CMS Child Core Set of Measures Hybrid Specifications (utilizing health record data for numerator inclusion) using HEDIS 2017 value sets. HHSC has removed references to state reporting requirements. Measure is reported for Rate 1 (Prenatal Care) only. Rate 2 (postnatal care) is not reported for DSIP reporting purposes.Additional InformationGuidance for Reporting:? If the Hybrid Method is used, a combination of administrative data and medical record review may not be used to identify prenatal care visits for an individual in the denominator. For example, for one woman, two prenatal care visits identified through administrative data and another three visits identified through medical record review (for a total of five prenatal care visits) may not be counted, even if each visit shows a different date of service.? This measure includes LOINC codes. Use of the LOINC codes is optional for this measure. If LOINC codes are not available, the other code systems in the value set may be used instead.? Include all paid, suspended, pending, and denied claims. Additional Notes: When counting prenatal visits, include visits with physician assistants, nurse practitioners, and midwives.Services that occur over multiple visits count toward this measure as long as all services are within the time frame established in the measure. Ultrasound and lab results alone should not be considered a visit; they must be linked to an office visit with an appropriate practitioner in order to count for this measure.Providers should use one date (date of delivery or EDD) to define the start and end of the first trimester. If multiple estimated dates of delivery (EDD) are documented, providers will define a method to determine which EDD to use, and use that date consistently. If a provider elects to use EDD, and the EDD is not on or between November 6 of the year prior to the measurement year and November 5 of the measurement year, the woman is excluded as a valid data error and replaced by the next woman of the oversample. The LMP may not be used to determine the first trimester.Providers may use EDD to identify the first trimester for the Timeliness of Prenatal Care rate.A Pap test alone does not count as a prenatal care visit for the Timeliness of Prenatal Care rate. A colposcopy alone is not numerator compliant.The intent is that a visit is with a PCP or OB/GYN practitioner. Ancillary services (lab, ultrasound) may be delivered by an ancillary provider.The intent of the measure is to assess whether prenatal and preventive care was rendered on a routine, outpatient basis rather than assessing treatment for emergent events. Definitions: PCP: 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 Obstetrical/Gynecological (OB/GYN) and Other Prenatal Care Practitioner: Includes:Physicians certified as obstetricians or gynecologists by the American Medical Specialties Board of Obstetrics or Gynecology or the American Osteopathic Association; or, if not certified, who successfully completed an accredited program of graduate medical or osteopathic education in obstetrics and gynecologyCertified nurse midwives, nurse practitioners, and physician assistants who deliver prenatal care services in a specialty setting (under the direction of an OB/GYN certified or accredited provider) Referenced Value Sets (List includes Rate 1 and 2 - value sets for Rate 2 Postpartum Care will not be needed): ? ABO: 2.16.840.1.113883.3.464.1004.1001? ABO and Rh: 2.16.840.1.113883.3.464.1004.1002? Cervical Cytology: 2.16.840.1.113883.3.464.1004.1208? Cytomegalovirus Antibody: 2.16.840.1.113883.3.464.1004.1069? Deliveries: 2.16.840.1.113883.3.464.1004.1072? Herpes Simplex Antibody: 2.16.840.1.113883.3.464.1004.1119? Non-live Births: 2.16.840.1.113883.3.464.1004.1187? Obstetric Panel: 2.16.840.1.113883.3.464.1004.1192? Postpartum Bundled Services: 2.16.840.1.113883.3.464.1004.1217? Postpartum Visits: 2.16.840.1.113883.3.464.1004.1218? Pregnancy Diagnosis: 2.16.840.1.113883.3.464.1004.1220? Prenatal Bundled Services: 2.16.840.1.113883.3.464.1004.1223? Prenatal Ultrasound: 2.16.840.1.113883.3.464.1004.1224? Prenatal Visits: 2.16.840.1.113883.3.464.1004.1225? Rh: 2.16.840.1.113883.3.464.1004.1228? Rubella Antibody: 2.16.840.1.113883.3.464.1004.1233? Stand Alone Prenatal Visits: 2.16.840.1.113883.3.464.1004.1240? Toxoplasma Antibody: 2.16.840.1.113883.3.464.1004.1253E1-235: 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 planningE1-235: Post-Partum Follow-Up and Care CoordinationDY7/DY8 Program IDE1-235Measure DetailsSteward: CMSNQF #: NASource: PQRS #336Data SourceAnyRequired StatusRequiredMeasure 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.E1-300: Behavioral Health Risk Assessment (for Pregnant Women)Measure Description:Percentage of women, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care who received a behavioral health screening risk assessment that includes the following screenings at the first prenatal visit: depression screening, alcohol use screening, tobacco use screening, drug use screening (illicit and prescription, over the counter), and intimate partner violence screening.E1-300: Behavioral Health Risk Assessment (for Pregnant Women)DY7/DY8 Program IDE1-300Measure DetailsSteward: CMSNQF #: NASource: Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set) 2017 SourceE.H.R.Required StatusRequiredMeasure 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, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care.Denominator InclusionsLOGIC: ENCOUNTER Performed, Prenatal Visit: "2.16.840.1.113883.3.526.3.1264"AND PROCEDURE Performed Vaginal Delivery: "2.16.840.1.113883.3.526.3.1341" Attribute: stop datetime Date of Delivery OR PROCEDURE Performed: Cesarean Section Delivery: "2.16.840.1.113883.3.526.3.1342" Attribute: stope datetime Dat of DeliveryDenominator ExclusionsNo Valid Denominator Exclusions or Exceptions for this Measure.Numerator DescriptionPatients who received all behavioral health screening risk assessments at the first prenatal visit.Numerator Inclusions (Performance Met)Patients who received the following behavioral health screening risk assessments at the first prenatal visit.Depression screening:? Patients who were screened for depression at the first visit. 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)].Alcohol use screening:? Patients who were screened for any alcohol use at the first visit Tobacco use screening:? Patients who were screened for tobacco use at the first visit Drug use (illicit and prescription, over the counter) screening:? Patients who were screened for any drug use at the first visitIntimate partner violence screening:? Patients who were screened for intimate partner violence/abuse at the first visit. 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. Intimate partner violence screening may include a self-reported validated depression screening tool (e.g., Hurt, Insult, Threaten, and Scream [HITS], Woman Abuse Screening Tool [WAST], Partner Violence Screen [PVS], Abuse Assessment Screen [AAS]).To satisfactorily meet the numerator, ALL screening components must be performed. LOGIC:All Patients Identified within the DenominatorAND RISK CATEGORY/ASSESSMENT Result; Depression Screening Tools Realted to Maternity Care: "2.16.840.1.113883.3.526.3.1359" Attirbute: Result Value Present OR INTERVENTION Result; Depression Screening-Procedure: "2.16.840.1.113883.3.526.3.1360" Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result; Alcohol Use Screening: "2.16.840.1.113883.3.526.3.1361"Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result; Tobacco Use Screening: "2.16.840.1.113883.3.526.3.1362"Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result; Illicit, Prescription and Over the Counter Drug Use Screening: "2.16.840.1.113883.3.526.3.1363"Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result, Intimate Partner Violence Screening-Tool; "2.16.840.1.113883.3.526.3.1364"Attribute: Result Value PresentNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional Information? To satisfactorily meet the numerator, all screening components must be performed.? The specifications for this measure do not include upper or lower age restrictions.? If an eligible woman has more than one birth during the measurement year, states should count each delivery separately in the Denominator (D). To be counted toward the numerator, each delivery must have a BHRA conducted at the first prenatal visit within the specified time frame for each delivery. Additional guidance can be found in the Medicaid and Chip Child Core Set Technical Specifications and Resource Manual for Federal Fiscal Year 2017 Allowable Exceptions: - Measure is specified for prenatal visits. For DSRIP reporting purposes, providers MAY include settings in addition to OB that may provide care to pregnant women. - Measure is specified so that denominator inclusion is determined by a delivery during the measurement period and a prenatal visit prior to delivery. For DSRIP repororting purposes, providers MAY deterimne denominator inclusion by a prenatal visit conducted during the measurement period, rather than delivery date within the measurement period. Providers should keep record of above exceptions and note them in the qualitative fields when reporting baseline or performance rates. Providers must apply exceptions consistantly across all baseline and performance years.Bundle E2 Maternal SafetyMeasure Bundle ObjectivesImprove maternal safety and reduce maternal morbidity through data driven interventions to prevent and manage obstetric hemorrhage.Target PopulationAll deliveries in a performing providers systemRelated System ComponentsBirthing HospitalNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNoMeasures Hospital BasedServicesYesE2-150: PC-02 Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section)Measure Description:Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birthE2-150: PC-02 Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section)DY7/DY8 Program IDE2-150Measure DetailsSteward: The Joint CommissionNQF #: 0471Source: Measure Information: Code Tables: : SourceAnyRequired StatusRequiredMeasure 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 DescriptionNulliparous patients delivered of a live term singleton newborn in vertex presentationDenominator InclusionsICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery (TJC Table 11.01.1: Delivery):10D00Z0 Extraction of Products of Conception, Classical, Open Approach10D00Z1 Extraction of Products of Conception, Low Cervical, Open Approach10D00Z2 Extraction of Products of Conception, Extraperitoneal, Open Approach10D07Z3 Extraction of Products of Conception, Low Forceps, Via Natural or Artificial Opening10D07Z4 Extraction of Products of Conception, Mid Forceps, Via Natural or Artificial Opening10D07Z5 Extraction of Products of Conception, High Forceps, Via Natural or Artificial Opening10D07Z6 Extraction of Products of Conception, Vacuum, Via Natural or Artificial Opening10D07Z7 Extraction of Products of Conception, Internal Version, Via Natural or Artificial Opening10D07Z8 Extraction of Products of Conception, Other, Via Natural or Artificial Opening10E0XZZ Delivery of Products of Conception, External Approach Nulliparous patients with ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for outcome of delivery and with a delivery of a newborn with 37 weeks or more of gestation completed (TJC Table 11.08: Outcome Delivery)Z370 Single live birthDenominator ExclusionsLess than 8 years of age ORGreater than or equal to 65 years of age ORLength of Stay >120 days OR Gestational Age < 37 weeks or UTD ORICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for multiple gestations and other presentations (TJC Table 11.09: Multiple Gestations and Other Presentations)O30001 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimesterO30002 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimesterO30003 Twin pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimesterO30011 Twin pregnancy, monochorionic/monoamniotic, first trimesterO30012 Twin pregnancy, monochorionic/monoamniotic, second trimesterO30013 Twin pregnancy, monochorionic/monoamniotic, third trimesterO30031 Twin pregnancy, monochorionic/diamniotic, first trimesterO30032 Twin pregnancy, monochorionic/diamniotic, second trimesterO30033 Twin pregnancy, monochorionic/diamniotic, third trimesterO30041 Twin pregnancy, dichorionic/diamniotic, first trimesterO30042 Twin pregnancy, dichorionic/diamniotic, second trimesterO30043 Twin pregnancy, dichorionic/diamniotic, third trimesterO30091 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimesterO30092 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimesterO30093 Twin pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimesterO30101 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimesterO30102 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimesterO30103 Triplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimesterO30111 Triplet pregnancy with two or more monochorionic fetuses, first trimesterO30112 Triplet pregnancy with two or more monochorionic fetuses, second trimesterO30113 Triplet pregnancy with two or more monochorionic fetuses, third trimesterO30121 Triplet pregnancy with two or more monoamniotic fetuses, first trimesterO30122 Triplet pregnancy with two or more monoamniotic fetuses, second trimesterO30123 Triplet pregnancy with two or more monoamniotic fetuses, third trimesterO30191 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimesterO30192 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimesterO30193 Triplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimesterO30201 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, first trimesterO30202 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, second trimesterO30203 Quadruplet pregnancy, unspecified number of placenta and unspecified number of amniotic sacs, third trimesterO30211 Quadruplet pregnancy with two or more monochorionic fetuses, first trimesterO30212 Quadruplet pregnancy with two or more monochorionic fetuses, second trimesterO30213 Quadruplet pregnancy with two or more monochorionic fetuses, third trimesterO30221 Quadruplet pregnancy with two or more monoamniotic fetuses, first trimesterO30222 Quadruplet pregnancy with two or more monoamniotic fetuses, second trimesterO30223 Quadruplet pregnancy with two or more monoamniotic fetuses, third trimesterO30291 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, first trimesterO30292 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, second trimesterO30293 Quadruplet pregnancy, unable to determine number of placenta and number of amniotic sacs, third trimesterO30801 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, first trimesterO30802 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, second trimesterO30803 Other specified multiple gestation, unspecified number of placenta and unspecified number of amniotic sacs, third trimesterO30811 Other specified multiple gestation with two or more monochorionic fetuses, first trimesterO30812 Other specified multiple gestation with two or more monochorionic fetuses, second trimesterO30813 Other specified multiple gestation with two or more monochorionic fetuses, third trimesterO30821 Other specified multiple gestation with two or more monoamniotic fetuses, first trimesterO30822 Other specified multiple gestation with two or more monoamniotic fetuses, second trimesterO30823 Other specified multiple gestation with two or more monoamniotic fetuses, third trimesterO30891 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, first trimesterO30892 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, second trimesterO30893 Other specified multiple gestation, unable to determine number of placenta and number of amniotic sacs, third trimesterO3091 Multiple gestation, unspecified, first trimesterO3092 Multiple gestation, unspecified, second trimesterO3093 Multiple gestation, unspecified, third trimesterO3111X0 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, not applicable or unspecifiedO3111X1 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 1O3111X2 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 2O3111X3 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 3O3111X4 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 4O3111X5 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, fetus 5O3111X9 Continuing pregnancy after spontaneous abortion of one fetus or more, first trimester, other fetusO3112X0 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, not applicable or unspecifiedO3112X1 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 1O3112X2 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 2O3112X3 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 3O3112X4 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 4O3112X5 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, fetus 5O3112X9 Continuing pregnancy after spontaneous abortion of one fetus or more, second trimester, other fetusO3113X0 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, not applicable or unspecifiedO3113X1 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 1O3113X2 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 2O3113X3 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 3O3113X4 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 4O3113X5 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, fetus 5O3113X9 Continuing pregnancy after spontaneous abortion of one fetus or more, third trimester, other fetusO3121X0 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, not applicable or unspecifiedO3121X1 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 1O3121X2 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 2O3121X3 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 3O3121X4 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 4O3121X5 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, fetus 5O3121X9 Continuing pregnancy after intrauterine death of one fetus or more, first trimester, other fetusO3122X0 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, not applicable or unspecifiedO3122X1 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 1O3122X2 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 2O3122X3 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 3O3122X4 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 4O3122X5 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, fetus 5O3122X9 Continuing pregnancy after intrauterine death of one fetus or more, second trimester, other fetusO3123X0 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, not applicable or unspecifiedO3123X1 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 1O3123X2 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 2O3123X3 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 3O3123X4 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 4O3123X5 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, fetus 5O3123X9 Continuing pregnancy after intrauterine death of one fetus or more, third trimester, other fetusO318X10 Other complications specific to multiple gestation, first trimester, not applicable or unspecifiedO318X11 Other complications specific to multiple gestation, first trimester, fetus 1O318X12 Other complications specific to multiple gestation, first trimester, fetus 2O318X13 Other complications specific to multiple gestation, first trimester, fetus 3O318X14 Other complications specific to multiple gestation, first trimester, fetus 4O318X15 Other complications specific to multiple gestation, first trimester, fetus 5O318X19 Other complications specific to multiple gestation, first trimester, other fetusO318X20 Other complications specific to multiple gestation, second trimester, not applicable or unspecifiedO318X21 Other complications specific to multiple gestation, second trimester, fetus 1O318X22 Other complications specific to multiple gestation, second trimester, fetus 2O318X23 Other complications specific to multiple gestation, second trimester, fetus 3O318X24 Other complications specific to multiple gestation, second trimester, fetus 4O318X25 Other complications specific to multiple gestation, second trimester, fetus 5O318X29 Other complications specific to multiple gestation, second trimester, other fetusO318X30 Other complications specific to multiple gestation, third trimester, not applicable or unspecifiedO318X31 Other complications specific to multiple gestation, third trimester, fetus 1O318X32 Other complications specific to multiple gestation, third trimester, fetus 2O318X33 Other complications specific to multiple gestation, third trimester, fetus 3O318X34 Other complications specific to multiple gestation, third trimester, fetus 4O318X35 Other complications specific to multiple gestation, third trimester, fetus 5O318X39 Other complications specific to multiple gestation, third trimester, other fetusO321XX0 Maternal care for breech presentation, not applicable or unspecifiedO321XX1 Maternal care for breech presentation, fetus 1O321XX2 Maternal care for breech presentation, fetus 2O321XX3 Maternal care for breech presentation, fetus 3O321XX4 Maternal care for breech presentation, fetus 4O321XX5 Maternal care for breech presentation, fetus 5O321XX9 Maternal care for breech presentation, other fetusO322XX0 Maternal care for transverse and oblique lie, not applicable or unspecifiedO322XX1 Maternal care for transverse and oblique lie, fetus 1O322XX2 Maternal care for transverse and oblique lie, fetus 2O322XX3 Maternal care for transverse and oblique lie, fetus 3O322XX4 Maternal care for transverse and oblique lie, fetus 4O322XX5 Maternal care for transverse and oblique lie, fetus 5O322XX9 Maternal care for transverse and oblique lie, other fetusO323XX0 Maternal care for face, brow and chin presentation, not applicable or unspecifiedO323XX1 Maternal care for face, brow and chin presentation, fetus 1O323XX2 Maternal care for face, brow and chin presentation, fetus 2O323XX3 Maternal care for face, brow and chin presentation, fetus 3O323XX4 Maternal care for face, brow and chin presentation, fetus 4O323XX5 Maternal care for face, brow and chin presentation, fetus 5O323XX9 Maternal care for face, brow and chin presentation, other fetusO328XX0 Maternal care for other malpresentation of fetus, not applicable or unspecifiedO328XX1 Maternal care for other malpresentation of fetus, fetus 1O328XX2 Maternal care for other malpresentation of fetus, fetus 2O328XX3 Maternal care for other malpresentation of fetus, fetus 3O328XX4 Maternal care for other malpresentation of fetus, fetus 4O328XX5 Maternal care for other malpresentation of fetus, fetus 5O328XX9 Maternal care for other malpresentation of fetus, other fetusO329XX0 Maternal care for malpresentation of fetus, unspecified, not applicable or unspecifiedO329XX1 Maternal care for malpresentation of fetus, unspecified, fetus 1O329XX2 Maternal care for malpresentation of fetus, unspecified, fetus 2O329XX3 Maternal care for malpresentation of fetus, unspecified, fetus 3O329XX4 Maternal care for malpresentation of fetus, unspecified, fetus 4O329XX5 Maternal care for malpresentation of fetus, unspecified, fetus 5O329XX9 Maternal care for malpresentation of fetus, unspecified, other fetusO3421 Maternal care for scar from previous cesarean deliveryO364XX0 Maternal care for intrauterine death, not applicable or unspecifiedO364XX1 Maternal care for intrauterine death, fetus 1O364XX2 Maternal care for intrauterine death, fetus 2O364XX3 Maternal care for intrauterine death, fetus 3O364XX4 Maternal care for intrauterine death, fetus 4O364XX5 Maternal care for intrauterine death, fetus 5O364XX9 Maternal care for intrauterine death, other fetusO6012X0 Preterm labor second trimester with preterm delivery second trimester, not applicable or unspecifiedO6012X1 Preterm labor second trimester with preterm delivery second trimester, fetus 1O6012X2 Preterm labor second trimester with preterm delivery second trimester, fetus 2O6012X3 Preterm labor second trimester with preterm delivery second trimester, fetus 3O6012X4 Preterm labor second trimester with preterm delivery second trimester, fetus 4O6012X5 Preterm labor second trimester with preterm delivery second trimester, fetus 5O6012X9 Preterm labor second trimester with preterm delivery second trimester, other fetusO6013X0 Preterm labor second trimester with preterm delivery third trimester, not applicable or unspecifiedO6013X1 Preterm labor second trimester with preterm delivery third trimester, fetus 1O6013X2 Preterm labor second trimester with preterm delivery third trimester, fetus 2O6013X3 Preterm labor second trimester with preterm delivery third trimester, fetus 3O6013X4 Preterm labor second trimester with preterm delivery third trimester, fetus 4O6013X5 Preterm labor second trimester with preterm delivery third trimester, fetus 5O6013X9 Preterm labor second trimester with preterm delivery third trimester, other fetusO6014X0 Preterm labor third trimester with preterm delivery third trimester, not applicable or unspecifiedO6014X1 Preterm labor third trimester with preterm delivery third trimester, fetus 1O6014X2 Preterm labor third trimester with preterm delivery third trimester, fetus 2O6014X3 Preterm labor third trimester with preterm delivery third trimester, fetus 3O6014X4 Preterm labor third trimester with preterm delivery third trimester, fetus 4O6014X5 Preterm labor third trimester with preterm delivery third trimester, fetus 5O6014X9 Preterm labor third trimester with preterm delivery third trimester, other fetusO6022X0 Term delivery with preterm labor, second trimester, not applicable or unspecifiedO6022X1 Term delivery with preterm labor, second trimester, fetus 1O6022X2 Term delivery with preterm labor, second trimester, fetus 2O6022X3 Term delivery with preterm labor, second trimester, fetus 3O6022X4 Term delivery with preterm labor, second trimester, fetus 4O6022X5 Term delivery with preterm labor, second trimester, fetus 5O6022X9 Term delivery with preterm labor, second trimester, other fetusO6023X0 Term delivery with preterm labor, third trimester, not applicable or unspecifiedO6023X1 Term delivery with preterm labor, third trimester, fetus 1O6023X2 Term delivery with preterm labor, third trimester, fetus 2O6023X3 Term delivery with preterm labor, third trimester, fetus 3O6023X4 Term delivery with preterm labor, third trimester, fetus 4O6023X5 Term delivery with preterm labor, third trimester, fetus 5O6023X9 Term delivery with preterm labor, third trimester, other fetusO632 Delayed delivery of second twin, triplet, etc.O641XX0 Obstructed labor due to breech presentation, not applicable or unspecifiedO641XX0 Obstructed labor due to breech presentation, not applicable or unspecifiedO641XX1 Obstructed labor due to breech presentation, fetus 1O641XX2 Obstructed labor due to breech presentation, fetus 2O641XX3 Obstructed labor due to breech presentation, fetus 3O641XX4 Obstructed labor due to breech presentation, fetus 4O641XX5 Obstructed labor due to breech presentation, fetus 5O641XX9 Obstructed labor due to breech presentation, other fetusO642XX0 Obstructed labor due to face presentation, not applicable or unspecifiedO642XX1 Obstructed labor due to face presentation, fetus 1O642XX2 Obstructed labor due to face presentation, fetus 2O642XX3 Obstructed labor due to face presentation, fetus 3O642XX4 Obstructed labor due to face presentation, fetus 4O642XX5 Obstructed labor due to face presentation, fetus 5O642XX9 Obstructed labor due to face presentation, other fetusO643XX0 Obstructed labor due to brow presentation, not applicable or unspecifiedO643XX1 Obstructed labor due to brow presentation, fetus 1O643XX2 Obstructed labor due to brow presentation, fetus 2O643XX3 Obstructed labor due to brow presentation, fetus 3O643XX4 Obstructed labor due to brow presentation, fetus 4O643XX5 Obstructed labor due to brow presentation, fetus 5O643XX9 Obstructed labor due to brow presentation, other fetusO648XX0 Obstructed labor due to other malposition and malpresentation, not applicable or unspecifiedO648XX1 Obstructed labor due to other malposition and malpresentation, fetus 1O648XX2 Obstructed labor due to other malposition and malpresentation, fetus 2O648XX3 Obstructed labor due to other malposition and malpresentation, fetus 3O648XX4 Obstructed labor due to other malposition and malpresentation, fetus 4O648XX5 Obstructed labor due to other malposition and malpresentation, fetus 5O648XX9 Obstructed labor due to other malposition and malpresentation, other fetusO661 Obstructed labor due to locked twinsO666 Obstructed labor due to other multiple fetusesP015 Newborn (suspected to be) affected by multiple pregnancyZ371 Single stillbirthZ372 Twins, both livebornZ373 Twins, one liveborn and one stillbornZ374 Twins, both stillbornZ3750 Multiple births, unspecified, all livebornZ3751 Triplets, all livebornZ3752 Quadruplets, all livebornZ3753 Quintuplets, all livebornZ3754 Sextuplets, all livebornZ3759 Other multiple births, all livebornZ3760 Multiple births, unspecified, some livebornZ3761 Triplets, some livebornZ3762 Quadruplets, some livebornZ3763 Quintuplets, some livebornZ3764 Sextuplets, some livebornZ3769 Other multiple births, some livebornZ377 Other multiple births, all stillbornNumerator DescriptionPatients with cesarean birthsNumerator Inclusions (Performance Met)ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for cesarean birth(TJC Table 11.06: Cesarean Birth)10D00Z0 Extraction of Products of Conception, Classical, Open Approach10D00Z1 Extraction of Products of Conception, Low Cervical, Open Approach10D00Z2 Extraction of Products of Conception, Extraperitoneal, Open ApproachNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNOTE: The specifications for DSRIP were built using the measure sources v2016A. For DSRIP reporting purposes providers may include new values added for 2018 for baseline and performance reporting. Additional InformationFollow TJC methodology for sampling: DATA ELEMENTSData Element Name: ICD-10-PCS Other Procedure CodesDefinition: The other or secondary (ICD-10-PCS) codes identifying all significant procedures other than the principal procedure.Note: If transmitted for the HBIPS measure set, all applicable edits (e.g., valid value, ICD-10-PCS Other Procedure Date exists, etc.) will apply.Suggested Data Collection Question: What were the ICD-10-PCS code(s) selected as other procedure(s) for this record?Allowable Values: Any valid procedure code as per the CMS ICD-10-PCS master code table (2016 PCS Long and Abbreviated Titles): Data Sources: Discharge summary, Face sheet, UB-04 Data Element Name: ICD-10-PCS Principal Procedure CodeDefinition: The principal procedure is the procedure performed for definitive treatment rather than diagnostic or exploratory purposes, or which is necessary to take care of a complication.Note: If transmitted for the HBIPS measure set, all applicable edits (e.g., valid value, ICD-10-PCS Principal Procedure Date exists, etc.) will apply.Suggested Data Collection Question: What was the ICD-10-PCS code selected as the principal procedure for this record?Allowable Values: Any valid procedure code as per the CMS ICD-10-PCS master code table (2016 PCS Long and Abbreviated Titles): Data Sources: Discharge summary, Face sheet, UB-04 Data Element Name: Admission DateDefinition: The month, day, and year of admission to acute inpatient care.Suggested Data Collection Question: What is the date the patient was admitted to acute inpatient care?Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (20xx)Notes for Abstraction: - The intent of this data element is to determine the date that the patient was actually admitted to acute inpatient care. Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the admission date is correct. If the abstractor determines through chart review that the date is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value.- If using claim information, the '‘Statement Covers Period'’ is not synonymous with the '‘Admission Date'’ and should not be used to abstract this data element. These are two distinctly different identifiers: - The Admission Date is purely the date the patient was admitted as an inpatient to the facility. - The Statement Covers Period ("“From"” and "“Through"” dates) identifies the span of service dates included in a particular claim. The “"From"” Date is the earliest date of service on the claim.- For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation.Example: Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to acute inpatient effective 04-05-20xx. The Admission Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written.- The admission date should not be abstracted from the earliest admission order without regards to substantiating documentation. If documentation suggests that the earliest admission order does not reflect the date the patient was admitted to inpatient care, this date should not be used.Example: Preoperative Orders are dated as 04-06-20xx with an order to admit to Inpatient. Postoperative Orders, dated 05-01-20xx, state to admit to acute inpatient. All other documentation supports that the patient presented to the hospital for surgery on 05-01-20xx. The Admission Date would be abstracted 05-01-20xx.- If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted.- For newborns that are born within this hospital, the Admission Date is the date the baby was born.Suggested Data Sources: ONLY ALLOWABLE SOURCES - Physician orders, Face sheet, UB-04Note: The physician order is the priority data source for this data element. If there is not a physician order in the medical record, use the other only allowable sources to determine the Admission Date.Excluded Data Sources:- UB-04, "“From"” and "“Through"” datesGuidelines for Abstraction:- Inclusion: None- Exclusion: Admit to observation, Arrival date Data Element Name: BirthdateDefinition: The month, day, and year the patient was born.Note: Patient's age (in years) is calculated by Admission Date minus Birthdate. The algorithm to calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age.For HBIPS discharge measures, i.e., HBIPS-1, 5, patient's age (in years) is calculated by Discharge Date minus Birthdate. For event measures, i.e., HBIPS-2, 3, patient's age at time of event (in years) is calculated by Event Date minus Birthdate. The algorithm to calculate age must use the month and day portion of birthdate, and discharge date or event, as appropriate to yield the most accurate age.Suggested Data Collection Question: What is the patient’s date of birth?Allowable Values: MM = Month (01-12)DD = Day (01-31)YYYY = Year (1880-Current Year)Notes for Abstraction: Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the birthdate is correct. If the abstractor determines through chart review that the date is incorrect, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct birthdate through chart review, she/he should default to the date of birth on the claim information.Suggested Data Sources: Emergency department record, Face sheet, Registration form, UB-04 Data Element Name: Discharge DateDefinition: The month, day, and year the patient was discharged from acute care, left against medical advice, or expired during this stay.Suggested Data Collection Question: What is the date the patient was discharged from acute care, left against medical advice (AMA), or expired?Allowable Values: MM = Month (01-12)DD = Day (01-31)YYYY = Year (20xx)Notes for Abstraction: Because this data element is critical in determining the population for many measures, the abstractor should NOT assume that the claim information for the discharge date is correct. If the abstractor determines through chart review that the date is incorrect, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct discharge date through chart review, she/he should default to the discharge date on the claim information.For HBIPS only, if the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, this information should be abstracted only once at the time of discharge from the hospital.Suggested Data Sources: Face sheet, Progress notes, Physician orders, Discharge summary, Nursing discharge notes, Transfer note, UB-04 Data Element Name: Gestational AgeDefinition: The weeks of gestation completed at the time of delivery.Gestational age is defined as the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation , irrespective of whether the gestation results in a live birth or a fetal death. This estimate of gestation should be determined by all perinatal factors and assessments such as ultrasound, but not the newborn exam. Ultrasound taken early in pregnancy is preferred (source: American College of Obstetricians and Gynecologists reVITALize Initiative).Suggested Data Collection Question: How many weeks of gestation were completed at the time of delivery?Allowable Values: 1-50UTD=Unable to DetermineNotes for Abstraction: Gestational age should be rounded off to the nearest completed week, not the following week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.The delivery or operating room record should be reviewed first for gestational age. If gestational age is not recorded in the delivery or operating room record, then continue to review the data sources in the following order: history and physical, prenatal forms,clinician admission progress note and discharge summary until a positive finding for gestational age is found. In cases where there is conflicting data, the gestational age found in the first document according to the order listed above should be used. The phrase "estimated gestational age" is an acceptable descriptor for gestational age.If the patient has not received prenatal care and no gestational age was documented, select allowable value UTD.When the admission date is different from the delivery date, use documentation of the gestational age completed closest to the delivery date.Gestational age should be documented by the clinician as a numeric value between 1-50. Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated using the best obstetrical Estimated Due Date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date)) / 7 (source: American College of Obstetricians and Gynecologists reVITALize Initiative). The clinician, not the abstractor, should perform the calculation to determine gestational age.If the gestational age entered by the clinician in the first document listed above is obviously incorrect (in error) but it is a valid number or two different numbers are listed in the first document and the correct number can be supported with documentation in the other acceptable data sources in the medical record, the correct number may be entered.Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN).It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below.The EHR takes precedence over a hand written entry if different gestational ages are documented in equivalent data sources, e.g., delivery record and delivery summary.ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE:1. Delivery record, note or summary2. Operating room record, note or summary3. History and physical4. Prenatal forms5. Admission clinician progress notes6. Discharge summary Data Element Name: ICD-10-CM Other Diagnosis CodesDefinition: The other or secondary (ICD-10-CM) codes associated with the diagnosis for this hospitalization.Suggested Data Collection Question: What were the ICD-10-CM other diagnosis codes selected for this medical record?Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2016 Code Descriptions in Tabular Order): Data Sources: Discharge summary, Face sheet, UB-04 Data Element Name: ICD-10-CM Principal Diagnosis CodeDefinition: The ICD-10-CM diagnosis code that is primarily responsbile for the admission of the patient to the hospital for care during this hospitalization.Suggested Data Collection Question: What was the ICD-10-CM code selected as the principal diagnosis for this record?Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2016 Code Descriptions in Tabular Order): Data Sources: Discharge summary, Face sheet, UB-04 Data Element Name: Number of Previous Live BirthsDefinition: The number of deliveries resulting in a live birth the patient experienced prior to current hospitalization.Suggested Data Collection Question: How many deliveries resulting in a live birth did the patient experience prior to current hospitalization?Allowable Values: - 0-50- UTD=Unable to DetermineNotes for Abstraction: - Parity may be used for the number of previous deliveries resulting in a live birth if zero is documented. For any number greater than zero, parity may ONLY be used provided there is additional documentation indicating the same number of live births experienced prior to this hospitalization. If the number for parity documented in the EHR is "one" and includes the delivery for the current hospitalization, abstract zero for previous live births.- The delivery or operating room record should be reviewed first for the number of previous live births. If the number of previous live births is not recorded in the delivery or operating room record, then continue to review the data sources in the following order: history and physical, prenatal forms,clinician admission progress note and discharge summary until a positive finding for the number of previous live births is found. In cases where there is conflicting data, the number of previous live births found in the first document according to the order listed in the Only Acceptable Sources should be used.- If gravidity is documented as one, the number of previous live births should be considered zero.- The previous delivery of live twins or any live multiple gestation is considered one live birth event.- Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN).- It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the Only Acceptable Sources listed below.- If primagravida or nulliparous is documented select zero for the number of previous live births.- GTPAL documentation alone does not indicate previous live births. Previous live births may be abstracted from an acceptable data source by adding the number of all previous Term plus Preterm deliveries minus the Stillbirths and the current delivery.- If the number of previous live births entered by the clinician in the first document listed is obviously incorrect (in error) but it is a valid number or two different numbers are listed in the first document and the correct number can be supported with documentation in the other acceptable data sources in the medical record, the correct number may be entered.Suggested Data Sources: ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE:1. Delivery record, note or summary2. Operating room record, note or summary3. History and physical4. Prenatal forms5. Admission clinician progress note6. Discharge summaryE2-151: PC-03 Antenatal SteroidsMeasure Description:Patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving antenatal steroids prior to delivering preterm newbornsE2-151: PC-03 Antenatal SteroidsDY7/DY8 Program IDE2-151Measure DetailsSteward: The Joint CommissionNQF #: 0476Source: Measure Information: Code Tables: : SourceAnyRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionPatients delivering live preterm newborns with >=24 and <34 weeks gestation completedDenominator InclusionsICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery asTJC Table 11.01.1 Delivery10D00Z0 Extraction of Products of Conception, Classical, Open Approach10D00Z1 Extraction of Products of Conception, Low Cervical, Open Approach10D00Z2 Extraction of Products of Conception, Extraperitoneal, Open Approach10D07Z3 Extraction of Products of Conception, Low Forceps, Via Natural or Artificial Opening10D07Z4 Extraction of Products of Conception, Mid Forceps, Via Natural or Artificial Opening10D07Z5 Extraction of Products of Conception, High Forceps, Via Natural or Artificial Opening10D07Z6 Extraction of Products of Conception, Vacuum, Via Natural or Artificial Opening10D07Z7 Extraction of Products of Conception, Internal Version, Via Natural or Artificial Opening10D07Z8 Extraction of Products of Conception, Other, Via Natural or Artificial Opening10E0XZZ Delivery of Products of Conception, External ApproachDenominator ExclusionsLess than 8 years of age ORGreater than or equal to 65 years of age ORLength of Stay >120 days ORDocumented Reason for Not Initiating Antenatal Steroids ORGestational Age < 24 or >= 34 weeks or UTD ORICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for fetal demise (TJC Table 11.09.1: Fetal Demise:)O364XX0 Maternal care for intrauterine death, not applicable or unspecifiedNumerator DescriptionPatients with antenatal steroids initiated prior to delivering preterm newbornsNumerator Inclusions (Performance Met)Antenatal steroids initiated (TJC Table 11.0, antenatal steroid medications)MEDICATION / GENERICBetamethasone / BetamethasoneBetamethasone Sodium Phosphate / Betamethasone Sodium PhosphateBetamethasone Sodium Phosphate and Betamethasone Acetate / Betamethasone Sodium Phosphate and Betamethasone AcetateCelestone / BetamethasoneCelestone Phosphate / Betamethasone Sodium PhosphateCelestone Soluspan / Betamethasone Sodium Phosphate and Betamethasone AcetateCortastat / Dexamethasone Sodium PhosphateDalalone / Dexamethasone Sodium PhosphateDalalone DP / Dexamethasone AcetateDalalone LA / Dexamethasone AcetateDecadron / DexamethasoneDecadron LA / Dexamethasone AcetateDecadron Phosphate / Dexamethasone Sodium PhosphateDecadron w/Xylocaine / Dexamethasone Sodium Phosphate with Lidocaine HCLDecaject / Dexamethasone Sodium PhosphateDecaject LA / Dexamethasone Sodium PhosphateDexamethasone / DexamethasoneDexamethasone Acetate / Dexamethasone AcetateDexamethasone Intensol / DexamethasoneDexamethasone Sodium Phosphate / Dexamethasone Sodium PhosphateDexamethasone Sodium Phosphate with Lidocaine / Dexamethasone Sodium Phosphate with LidocaineDexamethasone Sodium Phosphate with Lidocaine HCL / Dexamethasone Sodium Phosphate with Lidocaine HCLDexasone / Dexamethasone Sodium PhosphateDexasone LA / Dexamethasone AcetateDexone / DexamethasoneDexone LA / Dexamethasone AcetateHexadrol / DexamethasoneHexadrol Phosphate / Dexamethasone Sodium PhosphateSolurex / Dexamethasone Sodium PhosphateSolurex LA / Dexamethasone AcetateNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationFollow TJC methodology for sampling: DATA ELEMENTSData Element Name: Antenatal Steroids InitiatedDefinition: Documentation that antenatal steroids were initiated before delivery. Initial antenatal steroids are 12mg betamethasone IM or 6mg dexamethasone IM.Suggested Data Collection Question: Is there documentation that antenatal steroids were initiated before delivery?Allowable Values: - Y (Yes) There is documentation that antenatal steroids were initiated before delivery.- N (No) There is no documentation that antenatal steroids were initiated before delivery OR unable to determine from medical record documentation.Notes for Abstraction: - If there is documentation that antenatal steroids were initiated prior to current hospitalization in another setting of care, i.e., doctor's office, clinic, birthing center, hospital before delivery, select allowable value "yes".- If antenatal steroids were initiated in the hospital, the name of the medication must be documented in the medical record in order to select allowable value "yes".Suggested Data Sources: History and physical, Progress notes, Medication administration record (MAR), Prenatal forms Data Element Name: Admission DateDefinition: The month, day, and year of admission to acute inpatient care.Suggested Data Collection Question: What is the date the patient was admitted to acute inpatient care?Allowable Values: MM = Month (01-12) DD = Day (01-31) YYYY = Year (20xx)Notes for Abstraction: - The intent of this data element is to determine the date that the patient was actually admitted to acute inpatient care. Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the admission date is correct. If the abstractor determines through chart review that the date is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value.- If using claim information, the '‘Statement Covers Period'’ is not synonymous with the '‘Admission Date'’ and should not be used to abstract this data element. These are two distinctly different identifiers: - The Admission Date is purely the date the patient was admitted as an inpatient to the facility. - The Statement Covers Period ("“From"” and "“Through"” dates) identifies the span of service dates included in a particular claim. The “"From"” Date is the earliest date of service on the claim.- For patients who are admitted to Observation status and subsequently admitted to acute inpatient care, abstract the date that the determination was made to admit to acute inpatient care and the order was written. Do not abstract the date that the patient was admitted to Observation.Example: Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to acute inpatient effective 04-05-20xx. The Admission Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written.- The admission date should not be abstracted from the earliest admission order without regards to substantiating documentation. If documentation suggests that the earliest admission order does not reflect the date the patient was admitted to inpatient care, this date should not be used.Example: Preoperative Orders are dated as 04-06-20xx with an order to admit to Inpatient. Postoperative Orders, dated 05-01-20xx, state to admit to acute inpatient. All other documentation supports that the patient presented to the hospital for surgery on 05-01-20xx. The Admission Date would be abstracted 05-01-20xx.- If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted.- For newborns that are born within this hospital, the Admission Date is the date the baby was born.Suggested Data Sources: ONLY ALLOWABLE SOURCES - Physician orders, Face sheet, UB-04Note: The physician order is the priority data source for this data element. If there is not a physician order in the medical record, use the other only allowable sources to determine the Admission Date.Excluded Data Sources:- UB-04, "“From"” and "“Through"” datesGuidelines for Abstraction:- Inclusion: None- Exclusion: Admit to observation, Arrival date Data Element Name: BirthdateDefinition: The month, day, and year the patient was born.Note: Patient's age (in years) is calculated by Admission Date minus Birthdate. The algorithm to calculate age must use the month and day portion of admission date and birthdate to yield the most accurate age.For HBIPS discharge measures, i.e., HBIPS-1, 5, patient's age (in years) is calculated by Discharge Date minus Birthdate. For event measures, i.e., HBIPS-2, 3, patient's age at time of event (in years) is calculated by Event Date minus Birthdate. The algorithm to calculate age must use the month and day portion of birthdate, and discharge date or event, as appropriate to yield the most accurate age.Suggested Data Collection Question: What is the patient’s date of birth?Allowable Values: MM = Month (01-12)DD = Day (01-31)YYYY = Year (1880-Current Year)Notes for Abstraction: Because this data element is critical in determining the population for all measures, the abstractor should NOT assume that the claim information for the birthdate is correct. If the abstractor determines through chart review that the date is incorrect, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct birthdate through chart review, she/he should default to the date of birth on the claim information.Suggested Data Sources: Emergency department record, Face sheet, Registration form, UB-04 Data Element Name: Discharge DateDefinition: The month, day, and year the patient was discharged from acute care, left against medical advice, or expired during this stay.Suggested Data Collection Question: What is the date the patient was discharged from acute care, left against medical advice (AMA), or expired?Allowable Values: MM = Month (01-12)DD = Day (01-31)YYYY = Year (20xx)Notes for Abstraction: Because this data element is critical in determining the population for many measures, the abstractor should NOT assume that the claim information for the discharge date is correct. If the abstractor determines through chart review that the date is incorrect, she/he should correct and override the downloaded value. If the abstractor is unable to determine the correct discharge date through chart review, she/he should default to the discharge date on the claim information.For HBIPS only, if the patient was in an acute-care hospital and had multiple admissions to the psychiatric unit during his or her hospitalization, this information should be abstracted only once at the time of discharge from the hospital.Suggested Data Sources: Face sheet, Progress notes, Physician orders, Discharge summary, Nursing discharge notes, Transfer note, UB-04 Data Element Name: Gestational AgeDefinition: The weeks of gestation completed at the time of delivery.Gestational age is defined as the best obstetrical estimate (OE) of the newborn’s gestation in completed weeks based on the birth attendant’s final estimate of gestation , irrespective of whether the gestation results in a live birth or a fetal death. This estimate of gestation should be determined by all perinatal factors and assessments such as ultrasound, but not the newborn exam. Ultrasound taken early in pregnancy is preferred (source: American College of Obstetricians and Gynecologists reVITALize Initiative).Suggested Data Collection Question: How many weeks of gestation were completed at the time of delivery?Allowable Values: 1-50UTD=Unable to DetermineNotes for Abstraction: Gestational age should be rounded off to the nearest completed week, not the following week. For example, an infant born on the 5th day of the 36th week (35 weeks and 5/7 days) is at a gestational age of 35 weeks, not 36 weeks.The delivery or operating room record should be reviewed first for gestational age. If gestational age is not recorded in the delivery or operating room record, then continue to review the data sources in the following order: history and physical, prenatal forms,clinician admission progress note and discharge summary until a positive finding for gestational age is found. In cases where there is conflicting data, the gestational age found in the first document according to the order listed above should be used. The phrase "estimated gestational age" is an acceptable descriptor for gestational age.If the patient has not received prenatal care and no gestational age was documented, select allowable value UTD.When the admission date is different from the delivery date, use documentation of the gestational age completed closest to the delivery date.Gestational age should be documented by the clinician as a numeric value between 1-50. Gestational age (written with both weeks and days, eg. 39 weeks and 0 days) is calculated using the best obstetrical Estimated Due Date (EDD) based on the following formula: Gestational Age = (280 - (EDD - Reference Date)) / 7 (source: American College of Obstetricians and Gynecologists reVITALize Initiative). The clinician, not the abstractor, should perform the calculation to determine gestational age.If the gestational age entered by the clinician in the first document listed above is obviously incorrect (in error) but it is a valid number or two different numbers are listed in the first document and the correct number can be supported with documentation in the other acceptable data sources in the medical record, the correct number may be entered.Documentation in the acceptable data sources may be written by the following clinicians: physician, certified nurse midwife (CNM), advanced practice nurse/physician assistant (APN/PA) or registered nurse (RN).It is acceptable to use data derived from vital records reports received from state or local departments of public health, delivery logs or clinical information systems if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below.The EHR takes precedence over a hand written entry if different gestational ages are documented in equivalent data sources, e.g., delivery record and delivery summary.ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE:1. Delivery record, note or summary2. Operating room record, note or summary3. History and physical4. Prenatal forms5. Admission clinician progress notes6. Discharge summary Data Element Name: ICD-10-CM Other Diagnosis CodesDefinition: The other or secondary (ICD-10-CM) codes associated with the diagnosis for this hospitalization.Suggested Data Collection Question: What were the ICD-10-CM other diagnosis codes selected for this medical record?Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2016 Code Descriptions in Tabular Order): Data Sources: Discharge summary, Face sheet, UB-04 Data Element Name: ICD-10-CM Principal Diagnosis CodeDefinition: The ICD-10-CM diagnosis code that is primarily responsbile for the admission of the patient to the hospital for care during this hospitalization.Suggested Data Collection Question: What was the ICD-10-CM code selected as the principal diagnosis for this record?Allowable Values: Any valid diagnosis code as per the CMS ICD-10-CM master code table (2016 Code Descriptions in Tabular Order): Data Sources: Discharge summary, Face sheet, UB-04 Data Element Name: Reason for Not Initiating Antenatal SteroidsDefinition: Reasons for not initiating antenatal steroids before delivery are clearly documented in the medical record. Reasons for not initiating antenatal steroids may include fetal distress, imminent delivery or other reasons documented by physician/advanced practice nurse (APN)/physician assistant (PA)/certified nurse midwife (CNM).Initial antenatal steroids are 12mg betamethasone IM or 6mg dexamethasone IM.Suggested Data Collection Question: Is there documentation in the medical record of reasons for not initiating antenatal steroids before delivery?Allowable Values: - Y (Yes) There is documentation by physician/APN/PA/CNM that the patient has one or more reasons for not initiating antenatal steroids before delivery.- N (No) There is no documentation by physician/APN/PA/CNM of a reason for not initiating antenatal steroids before delivery or unable to determine from medical record documentation.Notes for Abstraction: When determining whether there is a reason documented by a physician/APN/PA or CNM for not initiating antenatal steroids, reasons must be explicitly documented (e.g., "patient had an adverse reaction to the medication in the past - unable to initiate antenatal steroids") or clearly implied (i.e., there is documentation of an imminent delivery which occurs within 2 hours after admission to the hospital, there is documentation the fetus has anomalies which are not compatible with life, there is documentation that the patient has chorioamnionitis).Suggested Data Sources: PHYSICIAN/APN/PA/CNM DOCUMENTATION ONLY - History and physical, Physician progress notes, Prenatal formsE2-A01: OB Hemorrhage Patient Safety ActivitiesMeasure Description:Participation in AIM OB Hemorrhage Safety Bundle Collaborative through Texas Department of State Health Services (DSHS). E2-A01: OB Hemorrhage Patient Safety ActivitiesDY7/DY8 Program IDE2-A01Measure DetailsSteward: NANQF #: NASource: NAData SourceNARequired StatusRequiredMeasure ClassificationType: Quality Improvement Collaborative ActivityMeasure Parts: 0Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit of Measurement for Payer TypeUnit: NANABaseline DetailsShortened baseline measurement period is allowed with justification submitted in the RHP Plan Update.Measure is not eligible for a baseline of 0.Denominator DescriptionNADenominator InclusionsNADenominator ExclusionsNANumerator DescriptionNANumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationP4R for participation in collaborative in DY7 and P4R for implementation of recommended practices in DY8Bundle F1 Improved Access to Adult Dental CareMeasure Bundle ObjectivesIncrease access to timely, appropriate dental care.Target PopulationAdults 18+ with one or more dental encounter during the measurement yearRelated System ComponentsDental Clinic including dental clinics in community settingsNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoF1-105: 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 userF1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionDY7/DY8 Program IDF1-105Measure DetailsSteward: NCQANQF #: 0028Source: CMS MIPS #226 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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.: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" Numerator 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.:NoneDSRIP 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)"F1-226: Chronic Disease Patients Accessing Dental ServicesMeasure Description:Percentage of patients with chronic disease conditions accessing dental services following referral by their medical providerF1-226: Chronic Disease Patients Accessing Dental ServicesDY7/DY8 Program IDF1-226Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusRequiredMeasure 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 referrals for dental services for chronic disease patients by medical providersDenominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionNumber of chronic disease patients who access dental services as the result of a referralNumerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneF1-227: Dental Caries: AdultsMeasure Description:Percentage of adults aged 18 or more years with untreated dental decayF1-227: Dental Caries: AdultsDY7/DY8 Program IDF1-227Measure DetailsSteward: Healthy People 2020NQF #: NASource: NAData SourceAnyRequired StatusRequiredMeasure 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 InformationNoneF1-T03: Innovative Measure: Preventative Care & Screening: Oral Cancer ScreeningMeasure Description:This measure is used to assess the percentage of patients aged 18 years and older who received oral cancer screening at each visit during the 12-month measurement period.F1-T03: Innovative Measure: Preventative Care & Screening: Oral Cancer ScreeningDY7/DY8 Program IDF1-T03Measure DetailsSteward: Texas A&M University College of DentistryNQF #: NASource: NAData SourceClaimsRequired StatusOptional Innovative MeasureMeasure ClassificationType: InnovativeMeasure Parts: 1Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit 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 DescriptionPatients aged 18 years and older as of the end of the measurement period who had a dental visit within the measurement period.Denominator InclusionsTBDDenominator ExclusionsPatients with a diagnosis of oral cancer, including squamous cell carcinoma, verrucous carcinoma, minor salivary gland carcinomas, and lymphomas.Numerator DescriptionPatients who were screened for Oral Cancer at each visit and a referral or biopsy is documented in the patient record if the screening results are abnormal. Screening must include visual and physical examination of tissues in the mouth to check for lumps or other abnormalities.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneBundle F2 Preventive Pediatric DentalMeasure Bundle ObjectivesExpand access to dental care including screening and preventative preventive dental services to improve long term oral health and quality of life and reduce costs by preventing the need for more intensive treatments.Target PopulationChildren (0 - 18) with one or more dental encounter during the measurement yearRelated System ComponentsDental Clinic including dental clinics in community settingsNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoF2-224: 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 teethF2-224: Dental Sealant: ChildrenDY7/DY8 Program IDF2-224Measure DetailsSteward: Healthy People 2020NQF #: NASource: SourceAnyRequired StatusRequiredMeasure 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 InformationNoneF2-229: Oral Evaluation: ChildrenMeasure Description:Percentage of children under age 21 years who received a comprehensive or periodic oral evaluation within the reporting year.F2-229: Oral Evaluation: ChildrenDY7/DY8 Program IDF2-229Measure DetailsSteward: American Dental AssociationNQF #: 2517Source: SourceClaimsRequired StatusRequiredMeasure 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 all children under age 21 with at least one (1) visit in the prior or current year.Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionUnduplicated number of children under age 21 years who received a comprehensive or periodic oral evaluation 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.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., date of birth), then STOP processing. This enrollee does not get counted in the denominator. Step 2. (Removed for DSRIP reporting purposes) Step 3. Check if subject received an oral evaluation as a dental service during the reporting year: a. If [CDT CODE] = D0120 or D0150 or D0145, AND b. If [RENDERING PROVIDER TAXONOMY] code = any of the NUCC maintained Provider Taxonomy Codes in Table 1 below, then include in numerator; proceed to next step.5 c. If both a AND b are not met, then the service was not provided as 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 1 should not be included in the numerator. Numerator: Step 4Denominator: Step 3 Table 1: 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.Bundle G1 Palliative CareMeasure Bundle ObjectivesProvide palliative care services to patients and their families and/or caregivers to improve patient outcomes and quality of life with a focus on relief from symptoms, stress, and pain related to serious, debilitating or terminal illness.Target PopulationIndividuals enrolled in palliative or hospice care program during the measurement year or the year prior to the measurement year per measure specificationsRelated System ComponentsHospice Program or Palliative Care Program including home based and community based programsNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNAMeasures Hospital BasedServicesNAG1-276: Hospice and Palliative Care – Pain AssessmentMeasure Description:Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.G1-276: Hospice and Palliative Care – Pain AssessmentDY7/DY8 Program IDG1-276Measure DetailsSteward: University of North Carolina-Chapel HillNQF #: 1637Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionPatients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting who report pain when pain screening is done on the admission evaluation / initial encounter.Denominator InclusionsThe Pain Assessment quality measure is intended for patients with serious illness who are enrolled in hospice care OR receive specialty palliative care in an acute hospital setting. Conditions may include, but are not limited to: cancer, heart disease, pulmonary disease, dementia and other progressive neurodegenerative diseases, stroke, HIV/AIDS, and advanced renal or hepaticfailure. For patients enrolled in hospice, a positive screen is indicated by any pain noted in screening (any response other than none on verbal scale, any number >0 on numerical scale or any observation or self-report of pain), due to the primacy of pain control and comfort care goals in hospice care. For patients receiving specialty palliative care, a positive screen is indicated by moderate or severe pain noted in screening (response of moderate or severe on verbal scale, >4 on a 10-point numerical scale, or any observation or self-report of moderate to severe pain). Only management of moderate or severe pain is targeted for palliative care patients, who have more diverse care goals. Individual clinicians and patients may still decide to assess mild pain, but this subset of patients is not included in the quality measure denominator. [NOTE: This quality measure should be paired with the Pain Screening quality measure to ensure that all patients are screened and therefore given the opportunity to report pain and enter the denominator population for Pain Assessment.]Denominator ExclusionsPatients with length of stay < 1 day in palliative care or < 7 days in hospice, patients who were not screened for pain. Patients who screen negative for pain are excluded from the denominator. Calculation of length of stay: discharge date - date of initial encounterNumerator DescriptionPatients who received a comprehensive clinical assessment to determine the severity, etiology and impact of their pain within 24 hours of screening positive for pain.Numerator Inclusions (Performance Met)Patients with a comprehensive clinical assessment including at least 5 of the following 7 characteristics of the pain: 1. location 2. severity 3. character 4. duration 5. frequency 6. what relieves or worsens the pain 7. the effect on function or quality of life.Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsProviders may exclude from the denominator patients who are non-verbal for whom no clinically appropriate pain assessment is availableAdditional InformationClinical assessment of Pain:a.Step 1- Identify all patients with serious, life-limiting illness who received either specialty palliative care in an acute hospital setting or hospice careb.Step 2- Identify admission evaluation / initial encounter dates; exclude palliative care patients if length of stay is less than one day. Exclude hospice patients if length of stay is less than 7 daysc.Step 3- Identify patients who were screened for pain during the admission evaluation (hospice) OR initial encounter (palliative care)d.Step 4- Identify patients who screened positive for pain [any pain if hospice; moderate or severe pain if palliative care].e.Step 5- Exclude patients who screened negative for painf.Step 6- Identify patients who received a clinical assessment for pain within 24 hours of screening positive for pain Numerator:Patients who received a clinical assessment for pain in Step 6 Denominator: Patients in Step 4 Sampling Methodology:Hospice and palliative care: consecutive sample of equal numbers of admissions + decedents beginning with a randomly selected date; minimum sample size 100.Data collection using a Structured medical record abstraction tool with separate collection of numerator and denominator values.G1-277: Hospice and Palliative Care – Treatment PreferencesMeasure Description:Percentage of patients with chart documentation of preferences for life sustaining treatments.G1-277: Hospice and Palliative Care – Treatment PreferencesDY7/DY8 Program IDG1-277Measure DetailsSteward: University of North Carolina-Chapel HillNQF #: 1641Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionSeriously ill patients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting.Denominator InclusionsThe Treatment Preferences quality measure is intended for patients with serious illness who are enrolled in hospice care OR receive specialty palliative care in an acute hospital setting. Conditions may include, but are not limited to: cancer, heart disease, pulmonary disease, dementia and other progressive neurodegenerative diseases, stroke, HIV/AIDS, and advanced renal or hepatic failure.Denominator ExclusionsPatients with length of stay < 1 day in palliative care or < 7 days in hospiceCalculation of length of stay; discharge date - date of initial encounterNumerator DescriptionPatients whose medical record includes documentation of life sustaining preferencesNumerator Inclusions (Performance Met)Documentation of life-sustaining treatment preferences should reflect patient self-report; if not available, discussion with surrogate decision-maker and/or review of advance directive documents are acceptable. The numerator condition is based on the process of eliciting and recording preferences, whether the preference statement is for or against the use of life-sustaining treatments. This item is meant to capture evidence of discussion and communication. Therefore, brief statements about an order written about lifesustaining treatment, such as “Full Code” or “DNR/DNI” do not count in the numerator. Documentation using the POLST paradigm with evidence of patient or surrogate involvement, such as co-signature or description of discussion, is adequate evidence and can be counted in this numerator.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationChart documentation of life sustaining preferences:a.Step 1- Identify all patients with serious, life-limiting illness who are enrolled in hospice OR who received specialty palliative carein an acute hospitalb.Step 2- Exclude palliative care patients if length of stay is < 1 day. Exclude hospice patients if length of stay is < 7 daysc.Step 3- Identify patients with documented discussion of preference for life sustaining treatments Numerator: Patients with documented discussion in Step 3 Denominator: Patients in Step 1 – Patients excluded in Step 2 Sampling Methodology:Hospice and palliative care: consecutive sample of equal numbers of admissions + decedents beginning with a randomly selected date.Data collection using a structured medical record abstraction tool, with separate collection of denominator and numerator dataG1-278: Beliefs and Values - Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discussMeasure Description:Percentage of hospice patients with documentation of a discussion of spiritual/religious concerns or documentation that the patient/caregiver/family did not want to discuss.G1-278: Beliefs and Values - Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discussDY7/DY8 Program IDG1-278Measure DetailsSteward: University of North Carolina-Chapel HillNQF #: 1647Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionSeriously ill patients 18 years of age or older enrolled in hospice.Denominator InclusionsThis quality measure is intended for patients with serious illness who are enrolled in hospice care. Conditions may include, but are not limited to: cancer, heart disease, pulmonary disease, dementia and other progressive neurodegenerative diseases, stroke, HIV/AIDS, and advanced renal or hepatic failureDenominator ExclusionsTesting has only been done with the adult population; thus patients younger than 18 are excluded.Numerator DescriptionPatients whose medical record includes documentation that the patient and/or caregiver was asked about spiritual/existential concerns within 5 days of the admission date.Numerator Inclusions (Performance Met)Examples of a discussion may include asking about patient’s need for spiritual or religious support, questions about the cause or meaning of illness or death. Other examples include discussion of God or a higher power related to illness, or offer of a spiritual resource including a chaplain. Discussion of spiritual or religious concerns may occur between patient and/or family and clergy or pastoral worker or patient and/or family and member of the interdisciplinary team.This item is meant to capture evidence of discussion and communication. Therefore, documentation of patient’s religious or spiritual affiliation by itself does not count for inclusion in numerator. Data are collected via chart review. Criteria are:1) evidence of a discussion about spiritual/religious concerns, or2) evidence that the patient, and/or family declined to engage in a conversation on thistopic.Evidence may be found in the initial screening/assessment, comprehensive assessment, update assessments within 5 days of admission to hospice, visit notes documented by any member of the team, and/or the spiritual care assessment. Cases are eligible for inclusion upon admission to a hospice program. The numerator criteria must be met during the time the patient is enrolled in the hospice program and can be met anytime during that period. The denominator/numerator data is collected within 1 to 12 months following discharge from hospice services.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationStep 1- Identify all patients with serious, life-limiting illness who quality for the denominator during the designated reporting period.Step 2- Exclude patients who are less than 18 years of age.Step 3- Identify patients with documented discussion of spiritual/religious concerns or documentation that the patient/family did not want to discuss spiritual/religious concerns. Numerator: Patients with documented discussion or who responded they did not want to discuss in Step 3 Denominator: patients in Step 1 – Patients excluded in Step 2G1-361: Patients Treated with an Opioid who are Given a Bowel RegimenMeasure Description:Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not neededG1-361: Patients Treated with an Opioid who are Given a Bowel RegimenDY7/DY8 Program IDG1-361Measure DetailsSteward: 0NQF #: 1617Source: HQRP: SourceAnyRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionType 1 patient stays, except for those with exclusions, in which scheduled opioid was initiated or continuedDenominator InclusionsNone listed by measure steward.Denominator Exclusions1. Under 18 years of age as indicated by the birth date (A0900) and admission date (A0220)OR2. Type 2 (discharged stays missing the admission record) and Type 3 patient stays (active stays)Numerator DescriptionThe numerator for the measure includes all patient stays from the denominator in which the patients are given a bowel regimen or have a documented reason for why a bowel regimen was not initiated or continued.Numerator Inclusions (Performance Met)The numerator for the measure includes all patient stays from the denominator in which the patient meets the following criteria:1. There is documentation of why a bowel regimen was not initiated or continued (N0520 = [1])OR2. A bowel regimen was initiated or continued within 1 day of a scheduled opioid being initiated or continued (N0520B – N0500B ≤ [1] and N0520B and N0500B ≠ [-,^]) All hospice stays, except those that meet the exclusion criteria, discharged during the 12 months are included in the denominator and are eligible for inclusion in the numerator. For patients with multiplestays during the 12-month time window, each stay is eligible for inclusion in the measure.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationThis measure is not risk-adjusted or stratified, and therefore, only the hospice-levelobserved score is computed. The measure logic of NQF #1617, Patients Treated with an Opioidwho are Given a Bowel Regimen, is as follows:1. Calculate the denominator count: ? Calculate the total number of patient stays that do not meet the exclusion criteria and a scheduled opioid was initiated or continued.2. Calculate the numerator count: ? Calculate the total number of Type 1 patient stays that indicates a documentation of why a bowel regimen was not initiated or continued or a bowel regimen was initiated or continued within 1 day of a scheduled opioid being initiated or continued. DEFINITIONS (The below definitions are specific to the Hospital Quality Reporting Program, and may be useful in generating DSRIP rates for this measure):Stay: The period of time between a patient’s admission to a hospice and either (a) a discharge, or (b) the end of the target period, whichever comes first. A patient can havemultiple stays assigned to a target period.? A patient stay starts with an admission record. The stay start date is the admission date on the HIS-Admission record.– When the admission record that starts a stay is missing (i.e., when a discharge record has no matching admission record for the same patient with the same admission date and in the same hospice), the stay start date is the admission date on the discharge record.? A patient stay ends with either (a) a HIS-Discharge record, or (b) the end of the target period, whichever comes first.– When a patient stay ends with a discharge record, the stay end date is the discharge date (A0270) on the discharge record.? The stay end date must be the same as or later than the stay start date.? Both the admission and the discharge records associated with the patient stay must have identical admission dates.– When a patient stay ends with the end of the target period (this typically indicates that the patient is still enrolled with the hospice at the end of the target period), the stay end date is the end of the target period.? The stay end date must be the same as or later than the stay start date. The admission and discharge records that define the start and the end of patient stays are paired by matching the patient identifier (State Code and Resident Internal ID), hospice identifier (Provider Internal Number) and admission date. If multiple admission records (or multiple discharge records) share the same information in these matching criteria, the last chronological submission is kept and used. The submission time is first determined by submission date and then, if multiple records are submitted on the same day, by the Hospice Assessment ID.? The definitions above generate three types of stays for a target period:- Type 1: stays with both the admission and the discharge records (i.e., discharged stays)- Type 2: stays with the discharge record but no admission record (i.e., discharged stays but missing the admission records)- Type 3: stays with the admission record but no discharge record (i.e., active stays as of the end of the target period)G1-362: Hospice and Palliative Care - Dyspnea TreatmentMeasure Description:Percentage of patients who screened positive for dyspnea who received treatment within 24 hours of screening.G1-362: Hospice and Palliative Care - Dyspnea TreatmentDY7/DY8 Program IDG1-362Measure DetailsSteward: University of North Carolina-Chapel HillNQF #: 1638Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionPatients enrolled in hospice for 7 or more days OR patients receiving palliative care who report dyspnea when dyspnea screening is done on the admission evaluation / initial encounter.Denominator InclusionsThe Dyspnea Treatment quality measure is intended for patients with serious illness who are enrolled in hospice care OR receive specialty palliative care in an acute hospital setting. Conditions may include, but are not limited to: cancer, heart disease, pulmonary disease, dementia and other progressive neurodegenerative diseases , stroke, HIV/AIDS, and advanced renal or hepatic failure. For patients enrolled in hospice or palliative care, a positive screen is indicated by any dyspnea noted as other than none on a verbal screen, any number > 0 on a numeric scale or any observational or self-report of dyspnea. [NOTE: This quality measure should be paired with the Dyspnea Screening quality measure to ensure that all patients are screened and therefore given the opportunity to report dyspnea and enter the denominator population for Dyspnea Treatment.]Denominator ExclusionsPalliative care patients with length of stay < 1 day or hospice patients with length of stay < 7 days, patients who were not screened for dyspnea, and/or patients with a negative screening.Discharge date – admission date = 1 or hospice patients with discharge date – admission date = 7.Numerator DescriptionPatients who screened positive for dyspnea who received treatment within 24 hours of screening.Numerator Inclusions (Performance Met)Treatment is administered if within 24 hours of the positive screen for dyspnea, medical treatment plan, orders or pharmacy records show inhaled medications, steroids, diuretics, or non-medication strategies such as oxygen and energy conservation. Treatment may also include benzodiazepine or opioid if clearly prescribed for dyspnea.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationDyspnea treatment:a.Step 1- Identify all patients with serious, life-limiting illness who received either specialty palliative care in an acute hospital settingor hospice careb.Step 2- Identify admission evaluation / initial encounter dates; exclude palliative care patients if length of stay is less than oneday. Exclude hospice patients if length of stay is less than 7 daysc.Step 3- Identify patients who were screened for dyspnea during the admission evaluation (hospice) / initial encounter (palliativecare)d.Step 4- Identify patients who screened positive for dyspneae.Step 5- Identify patients who received treatment within 24 hours of screening positive for dyspnea Numerator: Patients who received treatment for dyspnea in Step 5 Denominator: Patients in Step 4 Sampling Methodology: Hospice and palliative care: consecutive sample of equal numbers of admissions + decedents beginning with randomly selected date; minimum sample size 100.Data collection using a structured medical record abstraction tool, with separate collection of denominator and numerator dataG1-363: Hospice and Palliative Care - Dyspnea ScreeningMeasure Description:Percentage of hospice or palliative care patients who were screened for dyspnea during the hospice admission evaluation / palliative care initial encounter.G1-363: Hospice and Palliative Care - Dyspnea ScreeningDY7/DY8 Program IDG1-363Measure DetailsSteward: University of North Carolina-Chapel HillNQF #: 1639Source: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionPatients enrolled in hospice for 7 or more days OR patients receiving hospital-based palliative care for 1 or more days.Denominator InclusionsThe Dyspnea Screening quality measure is intended for patients with serious illness who are enrolled in hospice care OR receive specialty palliative care in an acute hospital setting. Conditions may include, but are not limited to: cancer, heart disease, pulmonary disease, dementia and other progressive neurodegenerative diseases, stroke, HIV/AIDS, and advanced renal or hepatic failure. [NOTE: This quality measure should be paired with the Dyspnea Treatment quality measure to ensure that all patients who report dyspnea are clinically considered for treatment.]Denominator ExclusionsPatients with length of stay < 7 days in hospice, or < 1 day in palliative care.Calculation of length of stay; discharge date - date of initial encounterNumerator DescriptionPatients who are screened for the presence or absence of dyspnea and its severity during the hospice admission evaluation / initial encounter for palliative care.Numerator Inclusions (Performance Met)Patients who are screened for the presence or absence of dyspnea during the admission evaluation for hospice / initial encounter for hospital-based palliative care, and asked to rate its severity. Screening may be completed using verbal, numeric, visual analog, or rating scales designed for use with non-verbal patients.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationScreened for dyspnea:a.Step 1- Identify all patients with serious, life-limiting illness who are enrolled in hospice care or who receive specialty palliative care in an acute hospital settingb.Step 2- Identify admission / initial encounter dates; exclude palliative care patients if length of stay is less than one day. Exclude hospice patients if length of stay is less than 7 daysc.Step 3- Identify patients who were screened for dyspnea during the admission evaluation (hospice) OR during the initial encounter (palliative care) Numerator: Patients screened for dyspnea in Step 3 Denominator: Patients in Step 1 – Patients excluded in Step 2 Sampling Methodology:Hospice and palliative care: consecutive sample of equal numbers of admissions + discharges beginning with a randomly selected date.Data collection using a structured medical record abstraction tool, with separate collection of denominator and numerator dataG1-505: Proportion Admitted to Hospice for less than 3 days (PQRS #457)Measure Description:Proportion of patients who died from cancer, and admitted to hospice and spent less than 3 days thereG1-505: Proportion Admitted to Hospice for less than 3 days (PQRS #457)DY7/DY8 Program IDG1-505Measure DetailsSteward: American Society of Clinical OncologyNQF #: 0216Source: CMS MIPS #457 RegistryData SourceAnyRequired StatusOptional for major cancer hospitals only (cannot select if you don't have a major cancer hospital)Measure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NADirectionality: 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 who died from cancer who were admitted to hospiceDenominator InclusionsDenominator Criteria (Eligible Cases):Diagnosis of cancer (ICD-10-CM): C00.0, C00.1, C00.2, C00.3, C00.4, C00.5, C00.6, C00.8, C00.9, C01, C02.0, C02.1, C02.2, C02.3, C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C05.9, C06.0, C06.1, C06.2, C06.80, C06.89, C06.9, C07, C08.0, C08.1, C08.9, C09.0, C09.1, C09.8, C09.9, C10.0, C10.1, C10.2, C10.3, C10.4, C10.8, C10.9, C11.0, C11.1, C11.2, C11.3, C11.8, C11.9, C12, C13.0, C13.1, C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C15.3, C15.4, C15.5, C15.8, C15.9, C16.1, C16.2, C16.3, C16.4, C16.5, C16.6, C16.8, C17.0, C17.1, C17.2, C17.3, C17.8, C17.9, C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C21.0, C21.1, C21.2, C21.8, C22.0, C22.1, C22.2, C22.3, C22.4, C22.7, C22.8, C22.9, C23, C24.0, C24.1, C24.8, C24.9, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C26.0, C26.1, C26.9, C30.0, C30.1, C31.0, C31.1, C31.2, C31.3, C31.8, C31.9, C32.0, C32.1, C32.2, C32.3, C32.8, C32.9, C33, C34.00, C34.01, C34.02, C34.10, C34.11, C34.12, C34.2, C34.30, C34.31, C34.32, C34.80, C34.81, C34.82, C34.90, C34.91, C34.92, C37, C38.0, C38.1, C38.2, C38.3, C38.4, C38.8, C39.0, C39.9, C40.00, C40.01, C40.02, C40.10, C40.11, C40.12, C40.20, C40.21, C40.22, C40.30, C40.31, C40.32, C40.80, C40.81, C40.82, C40.90, C40.91, C40.92, C41.0, C41.1, C41.2, C41.3, C41.4, C41.9, C43.0, C43.10, C43.11, C43.12, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9, C44.00, C44.01, C44.02, C44.09, C44.101, C44.102, C44.109, C44.111, C44.112, C44.119, C44.121, C44.122, C44.129, C44.191, C44.192, C44.199, C44.201, C44.202, C44.209, C44.211, C44.212, C44.219, C44.221, C44.222, C44.229, C44.291, C44.292, C44.299, C44.300, C44.301, C44.309, C44.310, C44.311, C44.319, C44.320, C44.321, C44.329, C44.390, C44.391, C44.399, C44.40, C44.41, C44.42, C44.49, C44.500, C44.501, C44.509, C44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.590, C44.591, C44.599, C44.601, C44.602, C44.609, C44.611, C44.612, C44.619, C44.621, C44.622, C44.629, C44.691, C44.692, C44.699, C44.701, C44.702, C44.709, C44.711, C44.712, C44.719, C44.721, C44.722, C44.729, C44.791, C44.792, C44.799, C44.80, C44.81, C44.82, C44.89, C44.90, C44.91, C44.92, C44.99, C45.0, C45.1, C45.2, C45.7, C45.9, C46.0, C46.1, C46.2, C46.3, C46.4, C46.50, C46.51, C46.52, C46.7, C46.9, C47.0, C47.10, C47.11, C47.12, C47.20, C47.21, C47.22, C47.3, C47.4, C47.5, C47.6, C47.8, C47.9, C48.0, C48.1, C48.2, C48.8, C49.0, C49.10, C49.11, C49.12, C49.20, C49.21, C49.22, C49.3, C49.A1, C49.A2, C49.A3, C49.A4, C49.A5, C49.A9, C49.5, C49.8, C49.9, C4A.0, C4A.10, C4A.11, C4A.12, C4A.20, C4A.21, C4A.22, C4A.30, C4A.31, C4A.39, C4A.4, C4A.51, C4A.52, C4A.59, C4A.60, C4A.61, C4A.62, C4A.70, C4A.71, C4A.72, C4A.8, C4A.9, C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322, C50.329, C50.411, C50.412, C50.419, C50.421, C50.422, C50.429, C50.511, C50.512, C50.519, C50.521, C50.522, C50.529, C50.611, C50.612, C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819, C50.821, C50.822, C50.829, C50.911, C50.912, C50.919, C50.921, C50.922, C50.929, C51.0, C51.1, C51.2, C51.8, C51.9, C52, C53.0, C53.1, C53.8, C53.9, C54.0, C54.1, C54.2, C54.3, C54.8, C54.9, C55, C56.1, C56.2, C56.9, C57.00, C57.01, C57.02, C57.10, C57.11, C57.12, C57.20, C57.21, C57.22, C57.3, C57.4, C57.7, C57.8, C57.9, C58, C60.0, C60.1, C60.2, C60.8, C60.9, C61, C62.00, C62.01, C62.02, C62.10, C62.11, C62.12, C62.90, C62.91, C62.92, C63.00, C63.01, C63.02, C63.10, C63.11, C63.12, C63.2, C63.7, C63.8, C63.9, C64.1, C64.2, C64.9, C65.1, C65.2, C65.9, C66.1, C66.2, C66.9, C67.0, C67.1, C67.2, C67.3, C67.4, C67.5, C67.6, C67.7, C67.8, C67.9, C68.0, C68.1, C68.8, C68.9, C69.00, C69.01, C69.02, C69.10, C69.11, C69.12, C69.20, C69.21, C69.22, C69.30, C69.31, C69.32, C69.40, C69.41, C69.42, C69.50, C69.51, C69.52, C69.60, C69.61, C69.62, C69.80, C69.81, C69.82, C69.90, C69.91, C69.92, C70.0, C70.1, C70.9, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C72.0, C72.1, C72.20, C72.21, C72.22, C72.30, C72.31, C72.32, C72.40, C72.41, C72.42, C72.50, C72.59, C72.9, C73, C74.00, C74.01, C74.02, C74.10, C74.11, C74.12, C74.90, C74.91, C74.92, C75.0, C75.1, C75.2, C75.3, C75.4, C75.5, C75.8, C75.9, C76.0, C76.1, C76.2, C76.3, C76.40, C76.41, C76.42, C76.50, C76.51, C76.52, C76.8, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C7A.00, C7A.010, C7A.011, C7A.012, C7A.019, C7A.020, C7A.021, C7A.022, C7A.023, C7A.024, C7A.025, C7A.026, C7A.029, C7A.090, C7A.091, C7A.092, C7A.093, C7A.094, C7A.095, C7A.096, C7A.098, C7A.1, C7A.8, C7B.00, C7B.01, C7B.02, C7B.03, C7B.04, C7B.09, C7B.1, C7B.8, C80.0, C80.1, C80.2, C81.00, C81.01, C81.02, C81.03, C81.04, C81.05, C81.06, C81.07, C81.08, C81.09, C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, C81.90, C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C82.00, C82.01, C82.02, C82.03, C82.04, C82.05, C82.06, C82.07, C82.08, C82.09, C82.10, C82.11, C82.12, C82.13, C82.14, C82.15, C82.16, C82.17, C82.18, C82.19, C82.20, C82.21, C82.22, C82.23, C82.24, C82.25, C82.26, C82.27, C82.28, C82.29, C82.30, C82.31, C82.32, C82.33, C82.34, C82.35, C82.36, C82.37, C82.38, C82.39, C82.40, C82.41, C82.42, C82.43, C82.44, C82.45, C82.46, C82.47, C82.48, C82.49, C82.50, C82.51, C82.52, C82.53, C82.54, C82.55, C82.56, C82.57, C82.58, C82.59, C82.60, C82.61, C82.62, C82.63, C82.64, C82.65, C82.66, C82.67, C82.68, C82.69, C82.80, C82.81, C82.82, C82.83, C82.84, C82.85, C82.86, C82.87, C82.88, C82.89, C82.90, C82.91, C82.92, C82.93, C82.94, C82.95, C82.96, C82.97, C82.98, C82.99, C83.00, C83.01, C83.02, C83.03, C83.04, C83.05, C83.06, C83.07, C83.08, C83.09, C83.10, C83.11, C83.12, C83.13, C83.14, C83.15, C83.16, C83.17, C83.18, C83.19, C83.30, C83.31, C83.32, C83.33, C83.34, C83.35, C83.36, C83.37, C83.38, C83.39, C83.50, C83.51, C83.52, C83.53, C83.54, C83.55, C83.56, C83.57, C83.58, C83.59, C83.70, C83.71, C83.72, C83.73, C83.74, C83.75, C83.76, C83.77, C83.78, C83.79, C83.80, C83.81, C83.82, C83.83, C83.84, C83.85, C83.86, C83.87, C83.88, C83.89, C83.90, C83.91, C83.92, C83.93, C83.94, C83.95, C83.96, C83.97, C83.98, C83.99, C84.00, C84.01, C84.02, C84.03, C84.04, C84.05, C84.06, C84.07, C84.08, C84.09, C84.10, C84.11, C84.12, C84.13, C84.14, C84.15, C84.16, C84.17, C84.18, C84.19, C84.40, C84.41, C84.42, C84.43, C84.44, C84.45, C84.46, C84.47, C84.48, C84.49, C84.60, C84.61, C84.62, C84.63, C84.64, C84.65, C84.66, C84.67, C84.68, C84.69, C84.70, C84.71, C84.72, C84.73, C84.74, C84.75, C84.76, C84.77, C84.78, C84.79, C84.90, C84.91, C84.92, C84.93, C84.94, C84.95, C84.96, C84.97, C84.98, C84.99, C84.A0, C84.A1, C84.A2, C84.A3, C84.A4, C84.A5, C84.A6, C84.A7, C84.A8, C84.A9, C84.Z0, C84.Z1, C84.Z2, C84.Z3, C84.Z4, C84.Z5, C84.Z6, C84.Z7, C84.Z8, C84.Z9, C85.10, C85.11, C85.12, C85.13, C85.14, C85.15, C85.16, C85.17, C85.18, C85.19, C85.20, C85.21, C85.22, C85.23, C85.24, C85.25, C85.26, C85.27, C85.28, C85.29, C85.80, C85.81, C85.82, C85.83, C85.84, C85.85, C85.86, C85.87, C85.88, C85.89, C85.90, C85.91, C85.92, C85.93, C85.94, C85.95, C85.96, C85.97, C85.98, C85.99, C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.0, C88.2, C88.3, C88.4, C88.8, C88.9, C90.00, C90.01, C90.02, C90.10, C90.11, C90.12, C90.20, C90.21, C90.22, C90.30, C90.31, C90.32, C91.00, C91.01, C91.02, C91.10, C91.11, C91.12, C91.30, C91.31, C91.32, C91.40, C91.41, C91.42, C91.50, C91.51, C91.52, C91.60, C91.61, C91.62, C91.90, C91.91, C91.92, C91.A0, C91.A1, C91.A2, C91.Z0, C91.Z1, C91.Z2, C92.00, C92.01, C92.02, C92.10, C92.11, C92.12, C92.20, C92.21, C92.22, C92.30, C92.31, C92.32, C92.40, C92.41, C92.42, C92.50, C92.51, C92.52, C92.60, C92.61, C92.62, C92.90, C92.91, C92.92, C92.A0, C92.A1, C92.A2, C92.Z0, C92.Z1, C92.Z2, C93.00, C93.01, C93.02, C93.10, C93.11, C93.12, C93.30, C93.31, C93.32, C93.90, C93.91, C93.92, C93.Z0, C93.Z1, C93.Z2, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.32, C94.40, C94.41, C94.42, C94.6, C94.80, C94.81, C94.82, C95.00, C95.01, C95.02, C95.10, C95.11, C95.12, C95.90, C95.91, C95.92, C96.0, C96.2, C96.4, C96.5, C96.6, C96.9, C96.A, C96.Z, D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, D46.A, D46.B, D46.C, D46.Z, D47.1, D47.Z2, D47.Z9ANDPatient encounter(s) during performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215ANDTwo or more encounters at the reporting siteANDPatient enrolled in hospice: G9858ANDPatients who died from cancer: G9859Denominator ExclusionsNoneNumerator DescriptionPatients who died from cancer and spent fewer than three days in hospiceNumerator Inclusions (Performance Met)Patient spent less than three days in hospice care (G9860)Numerator Exclusions (Performance Not Met)Patient spent greater than or equal to three days in hospice care (G9861)DSRIP Specific ModificationsNoneAdditional InformationNoneG1-507: Proportion Not Admitted to HospiceMeasure Description:Proportion of patients who died from cancer not admitted to hospiceG1-507: Proportion Not Admitted to HospiceDY7/DY8 Program IDG1-507Measure DetailsSteward: American Society of Clinical OncologyNQF #: 0215Source: CMS MIPS #456 RegistryData SourceAnyRequired StatusOptional for major cancer hospitals only (cannot select if you don't have a major cancer hospital)Measure ClassificationType: Clinical OutcomeMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NADirectionality: 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 who died from cancerDenominator InclusionsDiagnosis for cancer (ICD-10-CM): C00.0, C00.1, C00.2, C00.3, C00.4, C00.5, C00.6, C00.8, C00.9, C01, C02.0, C02.1, C02.2, C02.3, C02.4, C02.8, C02.9, C03.0, C03.1, C03.9, C04.0, C04.1, C04.8, C04.9, C05.0, C05.1, C05.2, C05.8, C05.9, C06.0, C06.1, C06.2, C06.80, C06.89, C06.9, C07, C08.0, C08.1, C08.9, C09.0, C09.1, C09.8, C09.9, C10.0, C10.1, C10.2, C10.3, C10.4, C10.8, C10.9, C11.0, C11.1, C11.2, C11.3, C11.8, C11.9, C12, C13.0, C13.1, C13.2, C13.8, C13.9, C14.0, C14.2, C14.8, C15.3, C15.4, C15.5, C15.8, C15.9, C16.1, C16.2, C16.3, C16.4, C16.5, C16.6, C16.8, C17.0, C17.1, C17.2, C17.3, C17.8, C17.9, C18.0, C18.1, C18.2, C18.3, C18.4, C18.5, C18.6, C18.7, C18.8, C18.9, C19, C20, C21.0, C21.1, C21.2, C21.8, C22.0, C22.1, C22.2, C22.3, C22.4, C22.7, C22.8, C22.9, C23, C24.0, C24.1, C24.8, C24.9, C25.0, C25.1, C25.2, C25.3, C25.4, C25.7, C25.8, C25.9, C26.0, C26.1, C26.9, C30.0, C30.1, C31.0, C31.1, C31.2, C31.3, C31.8, C31.9, C32.0, C32.1, C32.2, C32.3, C32.8, C32.9, C33, C34.00, C34.01, C34.02, C34.10, C34.11, C34.12, C34.2, C34.30, C34.31, C34.32, C34.80, C34.81, C34.82, C34.90, C34.91, C34.92, C37, C38.0, C38.1, C38.2, C38.3, C38.4, C38.8, C39.0, C39.9, C40.00, C40.01, C40.02, C40.10, C40.11, C40.12, C40.20, C40.21, C40.22, C40.30, C40.31, C40.32, C40.80, C40.81, C40.82, C40.90, C40.91, C40.92, C41.0, C41.1, C41.2, C41.3, C41.4, C41.9, C43.0, C43.10, C43.11, C43.12, C43.20, C43.21, C43.22, C43.30, C43.31, C43.39, C43.4, C43.51, C43.52, C43.59, C43.60, C43.61, C43.62, C43.70, C43.71, C43.72, C43.8, C43.9, C44.00, C44.01, C44.02, C44.09, C44.101, C44.102, C44.109, C44.111, C44.112, C44.119, C44.121, C44.122, C44.129, C44.191, C44.192, C44.199, C44.201, C44.202, C44.209, C44.211, C44.212, C44.219, C44.221, C44.222, C44.229, C44.291, C44.292, C44.299, C44.300, C44.301, C44.309, C44.310, C44.311, C44.319, C44.320, C44.321, C44.329, C44.390, C44.391, C44.399, C44.40, C44.41, C44.42, C44.49, C44.500, C44.501, C44.509, C44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.590, C44.591, C44.599, C44.601, C44.602, C44.609, C44.611, C44.612, C44.619, C44.621, C44.622, C44.629, C44.691, C44.692, C44.699, C44.701, C44.702, C44.709, C44.711, C44.712, C44.719, C44.721, C44.722, C44.729, C44.791, C44.792, C44.799, C44.80, C44.81, C44.82, C44.89, C44.90, C44.91, C44.92, C44.99, C45.0, C45.1, C45.2, C45.7, C45.9, C46.0, C46.1, C46.2, C46.3, C46.4, C46.50, C46.51, C46.52, C46.7, C46.9, C47.0, C47.10, C47.11, C47.12, C47.20, C47.21, C47.22, C47.3, C47.4, C47.5, C47.6, C47.8, C47.9, C48.0, C48.1, C48.2, C48.8, C49.0, C49.10, C49.11, C49.12, C49.20, C49.21, C49.22, C49.3, C49.A1, C49.A2, C49.A3, C49.A4, C49.A5, C49.A9, C49.5, C49.8, C49.9, C4A.0, C4A.10, C4A.11, C4A.12, C4A.20, C4A.21, C4A.22, C4A.30, C4A.31, C4A.39, C4A.4, C4A.51, C4A.52, C4A.59, C4A.60, C4A.61, C4A.62, C4A.70, C4A.71, C4A.72, C4A.8, C4A.9, C50.011, C50.012, C50.019, C50.021, C50.022, C50.029, C50.111, C50.112, C50.119, C50.121, C50.122, C50.129, C50.211, C50.212, C50.219, C50.221, C50.222, C50.229, C50.311, C50.312, C50.319, C50.321, C50.322, C50.329, C50.411, C50.412, C50.419, C50.421, C50.422, C50.429, C50.511, C50.512, C50.519, C50.521, C50.522, C50.529, C50.611, C50.612, C50.619, C50.621, C50.622, C50.629, C50.811, C50.812, C50.819, C50.821, C50.822, C50.829, C50.911, C50.912, C50.919, C50.921, C50.922, C50.929, C51.0, C51.1, C51.2, C51.8, C51.9, C52, C53.0, C53.1, C53.8, C53.9, C54.0, C54.1, C54.2, C54.3, C54.8, C54.9, C55, C56.1, C56.2, C56.9, C57.00, C57.01, C57.02, C57.10, C57.11, C57.12, C57.20, C57.21, C57.22, C57.3, C57.4, C57.7, C57.8, C57.9, C58, C60.0, C60.1, C60.2, C60.8, C60.9, C61, C62.00, C62.01, C62.02, C62.10, C62.11, C62.12, C62.90, C62.91, C62.92, C63.00, C63.01, C63.02, C63.10, C63.11, C63.12, C63.2, C63.7, C63.8, C63.9, C64.1, C64.2, C64.9, C65.1, C65.2, C65.9, C66.1, C66.2, C66.9, C67.0, C67.1, C67.2, C67.3, C67.4, C67.5, C67.6, C67.7, C67.8, C67.9, C68.0, C68.1, C68.8, C68.9, C69.00, C69.01, C69.02, C69.10, C69.11, C69.12, C69.20, C69.21, C69.22, C69.30, C69.31, C69.32, C69.40, C69.41, C69.42, C69.50, C69.51, C69.52, C69.60, C69.61, C69.62, C69.80, C69.81, C69.82, C69.90, C69.91, C69.92, C70.0, C70.1, C70.9, C71.0, C71.1, C71.2, C71.3, C71.4, C71.5, C71.6, C71.7, C71.8, C71.9, C72.0, C72.1, C72.20, C72.21, C72.22, C72.30, C72.31, C72.32, C72.40, C72.41, C72.42, C72.50, C72.59, C72.9, C73, C74.00, C74.01, C74.02, C74.10, C74.11, C74.12, C74.90, C74.91, C74.92, C75.0, C75.1, C75.2, C75.3, C75.4, C75.5, C75.8, C75.9, C76.0, C76.1, C76.2, C76.3, C76.40, C76.41, C76.42, C76.50, C76.51, C76.52, C76.8, C77.0, C77.1, C77.2, C77.3, C77.4, C77.5, C77.8, C77.9, C78.00, C78.01, C78.02, C78.1, C78.2, C78.30, C78.39, C78.4, C78.5, C78.6, C78.7, C78.80, C78.89, C79.00, C79.01, C79.02, C79.10, C79.11, C79.19, C79.2, C79.31, C79.32, C79.40, C79.49, C79.51, C79.52, C79.60, C79.61, C79.62, C79.70, C79.71, C79.72, C79.81, C79.82, C79.89, C79.9, C7A.00, C7A.010, C7A.011, C7A.012, C7A.019, C7A.020, C7A.021, C7A.022, C7A.023, C7A.024, C7A.025, C7A.026, C7A.029, C7A.090, C7A.091, C7A.092, C7A.093, C7A.094, C7A.095, C7A.096, C7A.098, C7A.1, C7A.8, C7B.00, C7B.01, C7B.02, C7B.03, C7B.04, C7B.09, C7B.1, C7B.8, C80.0, C80.1, C80.2, C81.00, C81.01, C81.02, C81.03, C81.04, C81.05, C81.06, C81.07, C81.08, C81.09, C81.10, C81.11, C81.12, C81.13, C81.14, C81.15, C81.16, C81.17, C81.18, C81.19, C81.20, C81.21, C81.22, C81.23, C81.24, C81.25, C81.26, C81.27, C81.28, C81.29, C81.30, C81.31, C81.32, C81.33, C81.34, C81.35, C81.36, C81.37, C81.38, C81.39, C81.40, C81.41, C81.42, C81.43, C81.44, C81.45, C81.46, C81.47, C81.48, C81.49, C81.70, C81.71, C81.72, C81.73, C81.74, C81.75, C81.76, C81.77, C81.78, C81.79, C81.90, C81.91, C81.92, C81.93, C81.94, C81.95, C81.96, C81.97, C81.98, C81.99, C82.00, C82.01, C82.02, C82.03, C82.04, C82.05, C82.06, C82.07, C82.08, C82.09, C82.10, C82.11, C82.12, C82.13, C82.14, C82.15, C82.16, C82.17, C82.18, C82.19, C82.20, C82.21, C82.22, C82.23, C82.24, C82.25, C82.26, C82.27, C82.28, C82.29, C82.30, C82.31, C82.32, C82.33, C82.34, C82.35, C82.36, C82.37, C82.38, C82.39, C82.40, C82.41, C82.42, C82.43, C82.44, C82.45, C82.46, C82.47, C82.48, C82.49, C82.50, C82.51, C82.52, C82.53, C82.54, C82.55, C82.56, C82.57, C82.58, C82.59, C82.60, C82.61, C82.62, C82.63, C82.64, C82.65, C82.66, C82.67, C82.68, C82.69, C82.80, C82.81, C82.82, C82.83, C82.84, C82.85, C82.86, C82.87, C82.88, C82.89, C82.90, C82.91, C82.92, C82.93, C82.94, C82.95, C82.96, C82.97, C82.98, C82.99, C83.00, C83.01, C83.02, C83.03, C83.04, C83.05, C83.06, C83.07, C83.08, C83.09, C83.10, C83.11, C83.12, C83.13, C83.14, C83.15, C83.16, C83.17, C83.18, C83.19, C83.30, C83.31, C83.32, C83.33, C83.34, C83.35, C83.36, C83.37, C83.38, C83.39, C83.50, C83.51, C83.52, C83.53, C83.54, C83.55, C83.56, C83.57, C83.58, C83.59, C83.70, C83.71, C83.72, C83.73, C83.74, C83.75, C83.76, C83.77, C83.78, C83.79, C83.80, C83.81, C83.82, C83.83, C83.84, C83.85, C83.86, C83.87, C83.88, C83.89, C83.90, C83.91, C83.92, C83.93, C83.94, C83.95, C83.96, C83.97, C83.98, C83.99, C84.00, C84.01, C84.02, C84.03, C84.04, C84.05, C84.06, C84.07, C84.08, C84.09, C84.10, C84.11, C84.12, C84.13, C84.14, C84.15, C84.16, C84.17, C84.18, C84.19, C84.40, C84.41, C84.42, C84.43, C84.44, C84.45, C84.46, C84.47, C84.48, C84.49, C84.60, C84.61, C84.62, C84.63, C84.64, C84.65, C84.66, C84.67, C84.68, C84.69, C84.70, C84.71, C84.72, C84.73, C84.74, C84.75, C84.76, C84.77, C84.78, C84.79, C84.90, C84.91, C84.92, C84.93, C84.94, C84.95, C84.96, C84.97, C84.98, C84.99, C84.A0, C84.A1, C84.A2, C84.A3, C84.A4, C84.A5, C84.A6, C84.A7, C84.A8, C84.A9, C84.Z0, C84.Z1, C84.Z2, C84.Z3, C84.Z4, C84.Z5, C84.Z6, C84.Z7, C84.Z8, C84.Z9, C85.10, C85.11, C85.12, C85.13, C85.14, C85.15, C85.16, C85.17, C85.18, C85.19, C85.20, C85.21, C85.22, C85.23, C85.24, C85.25, C85.26, C85.27, C85.28, C85.29, C85.80, C85.81, C85.82, C85.83, C85.84, C85.85, C85.86, C85.87, C85.88, C85.89, C85.90, C85.91, C85.92, C85.93, C85.94, C85.95, C85.96, C85.97, C85.98, C85.99, C86.0, C86.1, C86.2, C86.3, C86.4, C86.5, C86.6, C88.0, C88.2, C88.3, C88.4, C88.8, C88.9, C90.00, C90.01, C90.02, C90.10, C90.11, C90.12, C90.20, C90.21, C90.22, C90.30, C90.31, C90.32, C91.00, C91.01, C91.02, C91.10, C91.11, C91.12, C91.30, C91.31, C91.32, C91.40, C91.41, C91.42, C91.50, C91.51, C91.52, C91.60, C91.61, C91.62, C91.90, C91.91, C91.92, C91.A0, C91.A1, C91.A2, C91.Z0, C91.Z1, C91.Z2, C92.00, C92.01, C92.02, C92.10, C92.11, C92.12, C92.20, C92.21, C92.22, C92.30, C92.31, C92.32, C92.40, C92.41, C92.42, C92.50, C92.51, C92.52, C92.60, C92.61, C92.62, C92.90, C92.91, C92.92, C92.A0, C92.A1, C92.A2, C92.Z0, C92.Z1, C92.Z2, C93.00, C93.01, C93.02, C93.10, C93.11, C93.12, C93.30, C93.31, C93.32, C93.90, C93.91, C93.92, C93.Z0, C93.Z1, C93.Z2, C94.00, C94.01, C94.02, C94.20, C94.21, C94.22, C94.30, C94.31, C94.32, C94.40, C94.41, C94.42, C94.6, C94.80, C94.81, C94.82, C95.00, C95.01, C95.02, C95.10, C95.11, C95.12, C95.90, C95.91, C95.92, C96.0, C96.2, C96.4, C96.5, C96.6, C96.9, C96.A, C96.Z, D46.0, D46.1, D46.20, D46.21, D46.22, D46.4, D46.9, D46.A, D46.B, D46.C, D46.Z, D47.1, D47.Z2, D47.Z9ANDPatient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215ANDTwo or more encounters at the reporting siteANDPatients who died from cancer: G9855Denominator ExclusionsNoneNumerator DescriptionPatients not admitted to hospiceNumerator Inclusions (Performance Met)Patient was not admitted to hospice (G9856)Numerator Exclusions (Performance Not Met)Patient admitted to hospice (G9857)DSRIP Specific ModificationsNoneAdditional InformationNoneBundle H1 Integration of Behavioral Health in a Primary or Specialty Care SettingMeasure Bundle ObjectivesImplement depression, substance use disorder, and behavioral health screening and multi-modal treatment in a primary or non-psychiatric specialty care setting.Target PopulationDSRIP attributed individuals that meet one or more of the following criteria: a. Medicaid beneficiary attributed to the Performing Provider during the measurement period as determined by assignment to a primary care provider (PCP), medical home, or clinic in the performing providers DSRIP defined system. ORb. Individuals enrolled in a county based local coverage program assigned to a PCP, medical home, or clinic in the performing providers DSRIP defined system ORc. One preventive service provided during the measurement period (Includes value sets for annual wellness visit, preventive care services - initial office visit, preventive care services - established office visit, preventive care individual counseling) ORd. One ambulatory encounter during the measurement year and one ambulatory OR encounter during the year prior to the measurement year ORe. Two ambulatory encounters during the measurement year ORf. Other populations managed with chronic disease in specialty care clinics in the performing providers DSRIP defined system ORg. Three emergency department visits during the 24 month period ending with the end of the measurement periodRelated System ComponentsPrimary care, non-psychiatric outpatient specialty careNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesH1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD)Measure Description:Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documentedH1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD)DY7/DY8 Program IDH1-146Measure DetailsSteward: CMSNQF #: 0418Source: CMS MIPS #134 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 years and olderDenominator InclusionsCLAIMS/REGISTRY: Patients aged ≥ 12 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0101, G0402, G0438, G0439, G0444 E.H.R.: AND: Age>= 12 year(s) at: "Measurement Period" AND: "Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY: Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required: G9717ORScreening for depression not completed, documented reason (G8433) E.H.R.: OR: "Diagnosis: Depression diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) OR: "Diagnosis: Bipolar Diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" )Numerator DescriptionPatients screened for depression on the date of the encounter using an age appropriate standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screenNumerator Instructions: The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. The depression screening must be reviewed and addressed in the office of the provider filing the code on the date of the encounter. Definitions:Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to:? Adolescent Screening Tools (12-17 years):Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric Symptom Checklist (PSC-17), and PRIME MD-PHQ2 ? Adult Screening Tools (18 years and older)Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2 Follow-Up Plan – Documented follow-up for a positive depression screening must include one or more of the following:? Additional evaluation for depression? Suicide Risk Assessment? Referral to a practitioner who is qualified to diagnose and treat depression? Pharmacological interventions? Other interventions or follow-up for the diagnosis or treatment of depressionNot Eligible for Depression Screening or Follow-Up Plan –? Patient has an active diagnosis of Depression? Patient has a diagnosed Bipolar DisorderPatients with a Documented Reason for not Screening for Depression –One or more of the following conditions are documented:? Patient refuses to participate? Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status? Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of deliriumNumerator Inclusions (Performance Met)CLAIMS/REGISTRY: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)ORScreening for depression is documented as negative, a follow-up plan is not required (G8510) E.H.R.: AND: OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Negative Depression Screening)" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adolescent" "Intervention, Order: Referral for Depression Adolescent" "Medication, Order: Depression medications - adolescent" "Intervention, Performed: Follow-up for depression - adolescent" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adolescent Depression Screening" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Negative Depression Screening)" AND: Age>= 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adult" "Intervention, Order: Referral for Depression Adult" "Medication, Order: Depression medications - adult" "Intervention, Performed: Follow-up for depression - adult" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adult Depression Screening" AND: Age>= 18 year(s) at: "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Depression screening not documented, reason not given (G8432)ORScreening for depression documented as positive, follow-up plan not documented, reason not given (G8511) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Diagnosis: Bipolar Diagnosis" using "Bipolar Diagnosis Grouping Value Set (2.16.840.1.113883.3.600.450)"? "Diagnosis: Depression diagnosis" using "Depression diagnosis Grouping Value Set (2.16.840.1.113883.3.600.145)"? "Encounter, Performed: Depression Screening Encounter Codes" using "Depression Screening Encounter Codes Grouping Value Set (2.16.840.1.113883.3.600.1916)"? "Intervention, Order: Referral for Depression Adolescent" using "Referral for Depression Adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.537)"? "Intervention, Order: Referral for Depression Adult" using "Referral for Depression Adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.538)"? "Intervention, Performed: Additional evaluation for depression - adolescent" using "Additional evaluation for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.1542)"? "Intervention, Performed: Additional evaluation for depression - adult" using "Additional evaluation for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.1545)"? "Intervention, Performed: Follow-up for depression - adolescent" using "Follow-up for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.467)"? "Intervention, Performed: Follow-up for depression - adult" using "Follow-up for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.468)"? "Medication, Order: Depression medications - adolescent" using "Depression medications - adolescent RXNORM Value Set (2.16.840.1.113883.3.600.469)"? "Medication, Order: Depression medications - adult" using "Depression medications - adult RXNORM Value Set (2.16.840.1.113883.3.600.470)"? "Procedure, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment SNOMEDCT Value Set (2.16.840.1.113883.3.600.559)"? "Risk Category Assessment: Adolescent Depression Screening" using "Adolescent Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2452)"? "Risk Category Assessment: Adult Depression Screening" using "Adult Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2449)"? "Risk Category Assessment 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)"? "Risk Category Assessment not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Result: Negative Depression Screening" using "Negative Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2451)"? Attribute: "Result: Positive Depression Screening" using "Positive Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2450)"H1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD)Measure Description:Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a practitioner with prescribing authority during the 30-Day Initiation Phase.b. Percentage of children who remained on ADHD medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two additional follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.H1-255: Follow-up Care for Children Prescribed ADHD Medication (ADD)DY7/DY8 Program IDH1-255Measure DetailsSteward: National Committee for Quality AssuranceNQF #: 0108Source: CMS MIPS #366 eMeasure: SourceE.H.R.Required StatusRequiredMeasure ClassificationType: Clinical OutcomeMeasure Parts: 2Achievement 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 DescriptionInitial Population 1: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who had a visit during the measurement period. Initial Population 2: Children 6-12 years of age who were dispensed an ADHD medication during the Intake Period and who remained on the medication for at least 210 days out of the 300 days following the IPSD, and who had a visit during the measurement period. Exclusions: Denominator Exclusion 1: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period. Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 30 days after the IPSD. Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.Denominator Exclusion 2: Exclude patients diagnosed with narcolepsy at any point in their history or during the measurement period.Exclude patients who had an acute inpatient stay with a principal diagnosis of mental health or substance abuse during the 300 days after the IPSD.Exclude patients who were actively on an ADHD medication in the 120 days prior to the Index Prescription Start Date.Denominator InclusionsPopulation Criteria 1: AND: $InitialADHDMedication AND: Age>= 6 year(s) at: "Measurement Period" AND: Age< 12 year(s) at: "Measurement Period" AND: $Encounter Population Criteria 2: AND: $InitialADHDMedication AND: Sum>= 210 day(s): "Medication, Active: ADHD Medications (cumulative medication duration)" <= 300 day(s) starts after or concurrent with start of $InitialADHDMedication AND: Age>= 6 year(s) at: "Measurement Period" AND: Age< 12 year(s) at: "Measurement Period" AND: $EncounterDenominator ExclusionsPopulation Criteria 1: OR: "Diagnosis: Narcolepsy" starts before end of "Measurement Period" OR: Union of: "Encounter, Performed: Inpatient Encounter (principal diagnosis: Mental Health Diagnoses)" <= 30 day(s) starts after end of $InitialADHDMedication "Encounter, Performed: Inpatient Encounter (principal diagnosis: Substance Abuse)" <= 30 day(s) starts after end of $InitialADHDMedication OR: "Medication, Active: ADHD Medications" <= 120 day(s) starts before start of $InitialADHDMedication Population Criteria 2: OR: "Diagnosis: Narcolepsy" starts before end of "Measurement Period" OR: Union of: "Encounter, Performed: Inpatient Encounter (principal diagnosis: Mental Health Diagnoses)" <= 300 day(s) starts after end of $InitialADHDMedication "Encounter, Performed: Inpatient Encounter (principal diagnosis: Substance Abuse)" <= 300 day(s) starts after end of $InitialADHDMedication OR: "Medication, Active: ADHD Medications" <= 120 day(s) starts before start of $InitialADHDMedicationNumerator DescriptionRate 1: Patients who had at least one face-to-face visit with a practitioner with prescribing authority within 30 days after the IPSD. Rate 2: Patients who had at least one face-to-face visit with a practitioner with prescribing authority during the Initiation Phase, and at least two follow-up visits during the Continuation and Maintenance Phase. One of the two visits during the Continuation and Maintenance Phase may be a telephone visit with a practitioner.Numerator Inclusions (Performance Met)Population Criteria 1: AND: $Encounter30DaysAfterInitialADHDMed Population Criteria 2: AND: $Encounter30DaysAfterInitialADHDMed AND: OR: Count>= 2 : $EncounterAfterInitialMedication OR: AND: $EncounterAfterInitialMedication AND: Union of: "Encounter, Performed: Telehealth Services" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Telephone Management" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedicationNumerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsProviders that do not have access to pharmacy fill data should interpret specifications as medication prescribed rather than dispensedAdditional InformationDefinitions: - Intake Period: The five-month period starting 90 days prior to the start of the measurement period and ending 60 days after the start of the measurement period. - Index Prescription Start Date (IPSD): The earliest prescription dispensing date for an ADHD medication where the date is in the Intake Period and an ADHD medication was not dispensed during the 120 days prior. - Initiation Phase: The 30 days following the IPSD. - Continuation and Maintenance Phase: The 31-300 days following the IPSD.Guidance:- CUMULATIVE MEDICATION DURATION is an individual's total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.- To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.- For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period. Data Criteria (QDM Variables):? $Encounter = o 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"? $Encounter30DaysAfterInitialADHDMed = o Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Hospital Observation Care - Initial" "Encounter, Performed: Preventive Care Services - Group Counseling" "Encounter, Performed: Behavioral Health Follow-up Visit" "Encounter, Performed: Preventive Care Services-Individual Counseling" "Encounter, Performed: Psychotherapy and Pharmacologic Management (facility location: Ambulatory)" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Discharge Services- Observation Care" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" "Encounter, Performed: Psych Visit - Diagnostic Evaluation" "Encounter, Performed: Psych Visit - Psychotherapy" <= 30 day(s) ends after end of $InitialADHDMedication? $EncounterAfterInitialMedication = o Union of: "Encounter, Performed: Office Visit" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Hospital Observation Care - Initial" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care Services - Group Counseling" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Behavioral Health Follow-up Visit" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care Services-Individual Counseling" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Psychotherapy and Pharmacologic Management" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Face-to-Face Interaction" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Discharge Services- Observation Care" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Outpatient Consultation" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Home Healthcare Services" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care- Initial Office Visit, 0 to 17" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Preventive Care - Established Office Visit, 0 to 17" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Psych Visit - Diagnostic Evaluation" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication "Encounter, Performed: Psych Visit - Psychotherapy" satisfies all: >= 31 day(s) ends after end of $InitialADHDMedication <= 300 day(s) ends after end of $InitialADHDMedication? $InitialADHDMedication = o First: Union of: "Medication, Dispensed: ADHD Medications" <= 60 day(s) starts after start of "Measurement Period" "Medication, Dispensed: ADHD Medications" <= 90 day(s) starts before or concurrent with start of "Measurement Period"Data Criteria (QDM Data Elements):? "Diagnosis: Narcolepsy" using "Narcolepsy Grouping Value Set (2.16.840.1.113883.3.464.1003.114.12.1011)"? "Encounter, Performed: Behavioral Health Follow-up Visit" using "Behavioral Health Follow-up Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1054)"? "Encounter, Performed: Discharge Services- Observation Care" using "Discharge Services- Observation Care Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1039)"? "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: Hospital Observation Care - Initial" using "Hospital Observation Care - Initial Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1002)"? "Encounter, Performed: Inpatient Encounter" using "Inpatient Encounter Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1060)"? "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: 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)"? "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: Psychotherapy and Pharmacologic Management" using "Psychotherapy and Pharmacologic Management Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1055)"? "Encounter, Performed: Telehealth Services" using "Telehealth Services Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1031)"? "Encounter, Performed: Telephone Management" using "Telephone Management Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1053)"? "Medication, Active: ADHD Medications" using "ADHD Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1171)"? "Medication, Dispensed: ADHD Medications" using "ADHD Medications Grouping Value Set (2.16.840.1.113883.3.464.1003.196.12.1171)"? Attribute: "Principal diagnosis: Substance Abuse" using "Substance Abuse Grouping Value Set (2.16.840.1.113883.3.464.1003.106.12.1004)"? Attribute: "Principal diagnosis: Mental Health Diagnoses" using "Mental Health Diagnoses Grouping Value Set (2.16.840.1.113883.3.464.1003.105.12.1004)"? Attribute: "Facility location: Ambulatory" using "Ambulatory Grouping Value Set (2.16.840.1.113883.3.464.1003.122.12.1003)"H1-286: Depression Remission at Six MonthsMeasure Description:Adult patients age 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator.H1-286: Depression Remission at Six MonthsDY7/DY8 Program IDH1-286Measure DetailsSteward: MN Community MeasurementNQF #: 0711Source: CMS MIPS #411 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure 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 DescriptionAdults age 18 and older with a diagnosis of major depression or dysthymia and an initial (index) PHQ-9 score greater than nine Index Date - The first instance of elevated PHQ-9 greater than 9 and diagnosis of depression or dysthymia NOTE: To be considered denominator eligible for this measure, the patient must have both the diagnosis of depression or dysthymia and an index date PHQ-9 Score greater than 9 documented during the denominator identification measurement period. Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis.Denominator InclusionsDenominator Criteria (Eligible Cases):Patients aged ≥ 18 yearsANDDiagnosis for MDD (ICD-10-CM): F32.0, F32.1, F32.2, F32.3, F32.4, F32.5, F32.9, F33.0, F33.1, F33.2,F33.3, F33.40, F33.41, F33.42, F33.9, F34.1ANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837,99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439ANDIndex date PHQ-9 Score greater than 9 documented during the twelve month denominatoridentification period: G9511Denominator ExclusionsPatients with a diagnosis of bipolar disorder ICD10-CM: 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, F31.9ICD-9-CM: 296.00, 296.01, 296.02, 296.03, 296.04, 296.05, 296.06, 296.10, 296.11, 296.12, 296.13, 296.14, 296.15, 296.16, 296.40, 296.41, 296.42, 296.43, 296.44, 296.45, 296.46, 296.50, 296.51, 296.52, 296.53, 296.54, 296.55, 296.56, 296.60, 296.61, 296.62, 296.63, 296.64, 296.65, 296.66, 296.7, 296.80, 296.81, 296.82, 296.89ORPatients with a diagnosis of personality disorder:ICD-10-CM: F21, F34.0, F60.0, F60.1, F60.2, F60.3, F60.4, F60.5, F60.6, F60.7, F60.81, F60.89, F60.9, F68.10, F68.11, F68.12, F68.13ICD-9-CM: 301.0, 301.10, 301.11, 301.12, 301.13, 301.20, 301.21, 301.22, 301.3, 301.4, 301.50, 301.51, 301.59, 301.6, 301.7, 301.81, 301.82, 301.83, 301.84, 301.89, 301.9ORPatients who diedORPatients who received hospice or palliative care serviceORPatients who were permanent nursing home residentsNumerator DescriptionAdults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at six months as demonstrated by a six month (+/- 30 days) PHQ-9 score of less than five Definitions:Remission - a PHQ-9 score less than five.Six Months - the point in time from the index date extending out six months (+/- 30 days). Any PHQ-9 score less than five obtained during this two month period is deemed as remission at six months, values obtained prior to or after this period are not counted as numerator compliant (remission).Numerator Inclusions (Performance Met)Remission at six months as demonstrated by a six month (+/-30 days) PHQ-9 score of less than five (G9573)Numerator Exclusions (Performance Not Met)Remission at six months not demonstrated by a six month (+/-30 days) PHQ-9 score of less than five. Either PHQ-9 score was not assessed or is greater than or equal to five (G9574)DSRIP Specific ModificationsNoneAdditional InformationStandard Baseline Measurement Period: Measurement Period Index Period: June 3, 2016 through June 2, 2017Assessment Period: November 1, 2016 through December 31, 2017 PY1 Measurement Period: Measurement Period Index Period: June 3, 2017 through June 2, 2018Assessment Period: November 1, 2017 through December 31, 2018 PY2 Measurement Period: Measurement Period Index Period: June 3, 2018 through June 2, 2019Assessment Period: November 1, 2018 through December 31, 2019 PY3 Measurement Period: Measurement Period Index Period: June 3, 2019 through June 2, 2020Assessment Period: November 1, 2019 through December 31, 2020H1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingMeasure Description:Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol userH1-317: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief CounselingDY7/DY8 Program IDH1-317Measure DetailsSteward: AMA-convened Physician Consortium for Performance ImprovementNQF #: 2152Source: CMS MIPS #431 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 seen for at least two visits or at least one preventive visit during the measurement periodDenominator InclusionsPatients aged ≥ 18 yearsANDAt least two patient encounters during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90845, 96150, 96151, 96152, 97165, 97166, 97167, 97168, 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0270, G0271WITHOUTTelehealth Modifier: GQ, GTORAt Least One Preventive Visit during the performance period (CPT or HCPCS): 96160, 96161, 99385, 99386, 99387, 99395, 99396, 99397, 99401, 99402, 99403, 99404, 99411, 99412, 99429, G0438, G0439WITHOUTTelehealth Modifier: GQ, GTDenominator ExclusionsDocumentation of medical reason(s) for not screening for unhealthy alcohol use (e.g., limited life expectancy, other medical reasons) (G9623)Numerator DescriptionPatients who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user Definitions:Systematic screening method - For purposes of this measure, one of the following systematic methods toassess unhealthy alcohol use must be utilized. Systematic screening methods and thresholds for definingunhealthy alcohol use include:? AUDIT Screening Instrument (score ≥ 8)? AUDIT-C Screening Instrument (score ≥ 4 for men; score ≥ 3 for women)? Single Question Screening - How many times in the past year have you had 5 (for men) or 4 (forwomen and all adults older than 65 years) or more drinks in a day? (response ≥ 2) Brief counseling - Brief counseling for unhealthy alcohol use refers to one or more counseling sessions, aminimum of 5-15 minutes, which may include: feedback on alcohol use and harms; identification of high risksituations for drinking and coping strategies; increased motivation and the development of a personal plan toreduce drinking.NUMERATOR NOTE: In the event that a patient is screened for unhealthy alcohol use and identified as a userbut did not receive brief alcohol cessation counseling report G9624.Numerator Inclusions (Performance Met)Patient identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method and received brief counseling (G9621)ORPatient not identified as an unhealthy alcohol user when screened for unhealthy alcohol use using a systematic screening method (G9622)Numerator Exclusions (Performance Not Met)Patient not screened for unhealthy alcohol screening using a systematic screening method OR patient did not receive brief counseling, reason not given (G9624)DSRIP Specific ModificationsRemoved Medicare specific clarifications regarding non-covered services under Medicare Part B.Additional InformationNoneH1-T04: Innovative Measure: Engagement in Integrated Behavioral HealthMeasure Description:The percentage of children or youth initiating behavioral health care who received, or whose caregivers received, at least one follow-up behavioral health care or care management contact within 30 days of initiating behavioral health contact.H1-T04: Innovative Measure: Engagement in Integrated Behavioral HealthDY7/DY8 Program IDH1-T04Measure DetailsSteward: Meadows Mental Health Policy InstituteNQF #: NASource: NAData SourceE.H.R.Required StatusOptional Innovative MeasureMeasure ClassificationType: InnovativeMeasure Parts: 1Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit 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 DescriptionThe unduplicated number of children and youth who were documented in the electronic health record as having had an initial behavioral health service or contact (in-person, virtual, or telephonic).Denominator InclusionsBehavioral health contact can include an assessment, a treatment session, or any other type of contact that had a behavioral health focus and that was documented in the clinical record.Denominator ExclusionsChildren/youth and caregivers/families who refused subsequent behavioral health care or other assistance that was offered at the initial behavioral health contact, and for whom such refusal was documented in the clinical record, should be excluded from the analysis.Numerator DescriptionThe unduplicated number of children or youth who received, or whose caregivers received, a second contact (in-person, virtual, or telephonic) from a behavioral health provider, care coordinator, or care manager within 30 days of initial behavioral health contact, as documented in the electronic health record.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneBundle H2 Behavioral Health and Appropriate UtilizationMeasure Bundle ObjectivesProvide specialized and coordinated services to individuals with serious mental illness and/or a combination of behavioral health and physical health issues to reduce emergency department utilization and avoidable inpatient admission and readmissions.Target PopulationIndividuals included in the DSRIP attributed population with a diagnosis of serious mental Illness (bipolar, schizophrenia & schizoaffective disorders, MDD)Related System ComponentsOutpatient, ED or InpatientNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesYesH2-160: 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.H2-160: Follow-Up After Hospitalization for Mental IllnessDY7/DY8 Program IDH2-160Measure DetailsSteward: NCQANQF #: 0576Source: CMS MIPS #391 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequired to select at least one clinical required measure with additional points for further selectionsMeasure 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 health NOTE: 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 InformationNoneH2-216: Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission RateMeasure Description:Risk adjusted rate of hospital admissions for Behavioral Health /Substance Abuse (BH/SA) that had at least one readmission for any reason within 30 days of discharge for Behavioral Health or Substance abuse patients 18 years of age and older.A readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year.H2-216: Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission RateDY7/DY8 Program IDH2-216Measure DetailsSteward: NANQF #: NASource: NAData SourceClaims, otherRequired StatusRequired to select at least one clinical required measure with additional points for further selectionsMeasure 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 DescriptionExpected (risk-adjusted) number of readmissions for all-causes during the measurement year.The Expected number reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected number is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days. Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.Denominator InclusionsNoneDenominator ExclusionsNoneNumerator DescriptionObserved (Actual) jumber of readmissions within 30 days following an Index Admission for BH/SA during the measurement year.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSee risk adjusting guidance for additional informationH2-259: Assignment of Primary Care Physician to Individuals with SchizophreniaMeasure Description:The percentage of individuals with a primary diagnosis of schizophrenia that have been assigned a primary care physician.H2-259: Assignment of Primary Care Physician to Individuals with SchizophreniaDY7/DY8 Program IDH2-259Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusRequiredMeasure 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 DescriptionDSRIP Attributed Target Population with a primary diagnosis of schizophreniaDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionThe number of individuals in the denominator who were assigned a primary care physician.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsSpecified that the denominator is the DSRIP attributed target population with a diagnosis of schizophreniaAdditional InformationNoneH2-265: Housing Assessment for Individuals with SchizophreniaMeasure Description:The percentage of individuals with Schizophrenia whose housing quality was assessedH2-265: Housing Assessment for Individuals with SchizophreniaDY7/DY8 Program IDH2-265Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusOptional with additional points if selectedMeasure 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 DescriptionDSRIP Attributed Target Population with a primary diagnosis of schizophreniaDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionThe number of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsSpecified that the denominator is the DSRIP attributed target population with a diagnosis of schizophreniaAdditional InformationNoneH2-266: Independent Living Skills Assessment for Individuals with SchizophreniaMeasure Description:The percentage of patients who received an assessment of independent living skillsH2-266: Independent Living Skills Assessment for Individuals with SchizophreniaDY7/DY8 Program IDH2-266Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusRequiredMeasure 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 DescriptionDSRIP Attributed Target Population with a primary diagnosis of schizophreniaDenominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionPatients in the denominator who received an assessment of independent living skills.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsSpecified that the denominator is the DSRIP attributed target population with a diagnosis of schizophreniaAdditional InformationNoneH2-305: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH)Measure Description:Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide riskH2-305: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH)DY7/DY8 Program IDH2-305Measure DetailsSteward: AMA-convened Physician Consortium for Performance ImprovementNQF #: 1365Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorderDenominator InclusionsAND: Age>= 6 year(s) at: "Measurement Period" AND: Age< 17 year(s) at: "Measurement Period" AND: Occurrence A of $MDDEncounters177Denominator ExclusionsNoneNumerator DescriptionPatient visits with an assessment for suicide riskNumerator Inclusions (Performance Met)AND: "Intervention, Performed: Suicide Risk Assessment" during Occurrence A of $MDDEncounters177Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:- A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.- This measure is an episode-of-care measure; the level of analysis for this measure is every visit for major depressive disorder during the measurement period. For example, at every visit for MDD, the patient should have a suicide risk assessment.- Use of a standardized tool or instrument to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept Intervention, Performed: Suicide Risk Assessment included in the numerator logic below. Data Criteria (QDM Variables):? $MDDEncounters177 = o Union of: "Encounter, Performed: Office Visit (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Outpatient Consultation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Face-to-Face Interaction (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Diagnostic Evaluation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Family Psychotherapy (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psychoanalysis (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Group Psychotherapy (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Psychotherapy (diagnosis: Major Depressive Disorder-Active)" during "Measurement Period"Data Criteria (QDM Data Elements):? "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: Group Psychotherapy" using "Group Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1187)"? "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: 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 - Family Psychotherapy" using "Psych Visit - Family Psychotherapy Grouping Value Set (2.16.840.1.113883.3.526.3.1018)"? "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)"? "Intervention, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment Grouping Value Set (2.16.840.1.113883.3.526.3.1484)"? Attribute: "Diagnosis: Major Depressive Disorder-Active" using "Major Depressive Disorder-Active Grouping Value Set (2.16.840.1.113883.3.526.3.1491)"H2-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure)Measure Description:Percentage of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedH2-319: Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure)DY7/DY8 Program IDH2-319Measure DetailsSteward: PCPI(R) Foundation (PCPI[R])NQF #: 0104Source: eMeasure: SourceE.H.R.Required StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll patients aged 18 years and older with a diagnosis of major depressive disorder (MDD)Denominator InclusionsAND: Age>= 17 year(s) at: "Measurement Period" AND: Occurrence A of $MDDEncounters161 AND NOT: $MDDEncounters161 < 105 day(s) ends before start of Occurrence A of $MDDEncounters161Denominator ExclusionsNoneNumerator DescriptionPatients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identifiedNumerator Inclusions (Performance Met)AND: "Intervention, Performed: Suicide Risk Assessment" during Occurrence A of $MDDEncounters161Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:- This measure is an episode-of-care measure and should be reported for each instance of a new or recurrent episode of major depressive disorder (MDD); every new or recurrent episode will count separately in the Initial Population.- It is expected that a suicide risk assessment will be completed at the visit during which a new diagnosis is made or at the visit during which a recurrent episode is first identified (ie, at the initial evaluation). For the purposes of this measure, an episode of MDD would be considered to be recurrent if a patient has not had an MDD-related encounter in the past 105 days. If there is a gap of 105 or more days between visits for MDD, that would imply a recurrent episode. The 105-day look-back period is an operational provision and not a clinical recommendation, or definition of relapse, remission, or recurrence.- Use of a standardized tool or instrument to assess suicide risk will meet numerator performance. Standardized tools can be mapped to the concept Intervention, Performed: Suicide Risk Assessment included in the numerator logic below.- The measure description outlined in the header for this measure states, 'patients aged 18 years and older' while the logic statement states, '>= 17 year(s) at: Measurement Period'. The logic statement, as written, captures patients who turn 18 years old during the measurement period so that these patients are included in the measure. To ensure all patients with major depressive disorder (MDD) are assessed for suicide risk, there are two clinical quality measures addressing suicide risk assessment; CMS 177 covers children and adolescents aged 6 through 17, and CMS 161 covers the adult population aged 18 years and older. Data Criteria (QDM Variables):? $MDDEncounters161 = o Union of: "Encounter, Performed: Psych Visit - Diagnostic Evaluation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psych Visit - Psychotherapy (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Emergency Department Visit (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Office Visit (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Outpatient Consultation (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Psychoanalysis (diagnosis: Major Depressive Disorder-Active)" "Encounter, Performed: Face-to-Face Interaction (diagnosis: Major Depressive Disorder-Active)" during "Measurement Period" Data Criteria (QDM Data Elements):? "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit Grouping Value Set (2.16.840.1.113883.3.464.1003.101.12.1010)"? "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: 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: 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)"? "Intervention, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment Grouping Value Set (2.16.840.1.113883.3.526.3.1484)"? Attribute: "Diagnosis: Major Depressive Disorder-Active" using "Major Depressive Disorder-Active Grouping Value Set (2.16.840.1.113883.3.526.3.1491)"H2-405: Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance useMeasure Description:Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance useH2-405: Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance useDY7/DY8 Program IDH2-405Measure DetailsSteward: CMS/Center for Quality Assessment and Improvement in Mental HealthNQF #: NASource: eMeasure: SourceE.H.R.Required StatusRequiredMeasure 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 DescriptionPatients 18 years of age or older at the start of the measurement period with a new diagnosis of unipolar depression or bipolar disorder during the first 323 days of the measurement period, and evidence of treatment for unipolar depression or bipolar disorder within 42 days of diagnosis. The existence of a 'new diagnosis' is established by the absence of diagnoses and treatments of unipolar depression or bipolar disorder during the 180 days prior to the diagnosis.Denominator InclusionsInitial Population = AND: Age>= 18 year(s) at: "Measurement Period" AND: Union of: - $Treatments - "Encounter, Performed: BH Outpatient Psychotherapy" - <= 42 day(s) starts after start of Union of: Occurrence A of $BHEncounter Occurrence A of $BHOutptPsychotherapy AND NOT: Occurrence A of $BHEncounter < 180 day(s) starts after start of Union of: "Encounter, Performed: BH Outpatient encounter" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" - during "Medication, Active: BH Antidepressant Medication" - during "Medication, Active: BH Mood Stabilizer Medication" "Encounter, Performed: BH Outpatient Psychotherapy" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" Union of: - "Diagnosis: BH Condition Involving Unipolar Depression" - "Diagnosis: BH Condition Involving Bipolar Disorder" - starts during Union of: - "Encounter, Performed: BH Outpatient encounter" - "Encounter, Performed: BH Outpatient Psychotherapy" $Treatments AND NOT: Occurrence A of $BHOutptPsychotherapy < 180 day(s) starts after start of Union of: "Encounter, Performed: BH Outpatient encounter" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" - during "Medication, Active: BH Antidepressant Medication" - during "Medication, Active: BH Mood Stabilizer Medication" "Encounter, Performed: BH Outpatient Psychotherapy" satisfies any: - during "Diagnosis: BH Condition Involving Bipolar Disorder" - during "Diagnosis: BH Condition Involving Unipolar Depression" Union of: - "Diagnosis: BH Condition Involving Unipolar Depression" - "Diagnosis: BH Condition Involving Bipolar Disorder" - starts during Union of: - "Encounter, Performed: BH Outpatient encounter" - "Encounter, Performed: BH Outpatient Psychotherapy" $TreatmentsDenominator = AND: Initial PopulationDenominator ExclusionsNoneNumerator DescriptionPatients in the denominator with evidence of an assessment for alcohol or other substance use following or concurrent with the new diagnosis, and prior to or concurrent with the initiation of treatment for that diagnosisNumerator Inclusions (Performance Met)Numerator = AND: "Procedure, Performed: BH Assessment for Alcohol or Other Drugs" satisfies all: starts after or concurrent with start of Union of: - Occurrence A of $BHEncounter - Occurrence A of $BHOutptPsychotherapy ends before or concurrent with start of (Union of: - First: $Treatments - "Encounter, Performed: BH Outpatient Psychotherapy" - <= 42 day(s) starts after start of Union of: - Occurrence A of $BHEncounter - Occurrence A of $BHOutptPsychotherapy )Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGUIDANCE: The intent of the measure is that the assessment be performed for a single episode for each patient. Due to current limitations of the eMeasure specification system, it is possible for there to be up to two treatment episodes per patient, identified through up to two index episodes. As a result, the numerator criteria of this measure can be satisfied if a substance use assessment is performed within either treatment episode. Future versions of the measure should address this issue. A BH Outpatient Psychotherapy encounter meets the intent of both an encounter and a treatment.Data Criteria (QDM Variables) $BHEncounter = "Encounter, Performed: BH Outpatient encounter" satisfies all: - >= 42 day(s) starts before end of "Measurement Period" - starts after start of "Measurement Period" - satisfies any: satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Unipolar Depression" - overlaps "Diagnosis: BH Condition Involving Unipolar Depression" satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Bipolar Disorder" - overlaps "Diagnosis: BH Condition Involving Bipolar Disorder" $BHOutptPsychotherapy = "Encounter, Performed: BH Outpatient Psychotherapy" satisfies all: - >= 42 day(s) starts before end of "Measurement Period" - starts after start of "Measurement Period" - satisfies any: satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Unipolar Depression" - overlaps "Diagnosis: BH Condition Involving Unipolar Depression" satisfies all: - starts before or concurrent with start of "Diagnosis: BH Condition Involving Bipolar Disorder" - overlaps "Diagnosis: BH Condition Involving Bipolar Disorder" $Treatments = Union of: - "Procedure, Performed: BH Electroconvulsive Therapy" - "Procedure, Order: BH Electroconvulsive Therapy" - "Medication, Order: BH Antidepressant Medication" - "Medication, Order: BH Mood Stabilizer Medication" - "Procedure, Performed: BH Counseling for Depression" - "Procedure, Order: BH Counseling for Depression" Data Criteria (QDM Data Elements):- "Diagnosis: BH Condition Involving Bipolar Disorder" using "BH Condition Involving Bipolar Disorder Grouping Value Set (2.16.840.1.113883.3.1257.1.1504)"- "Diagnosis: BH Condition Involving Unipolar Depression" using "BH Condition Involving Unipolar Depression Grouping Value Set (2.16.840.1.113883.3.1257.1.1505)"- "Encounter, Performed: BH Outpatient encounter" using "BH Outpatient encounter Grouping Value Set (2.16.840.1.113883.3.464.1.49)"- "Encounter, Performed: BH Outpatient Psychotherapy" using "BH Outpatient Psychotherapy Grouping Value Set (2.16.840.1.113883.3.1257.1.973)"- "Medication, Active: BH Antidepressant Medication" using "BH Antidepressant Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.972)"- "Medication, Active: BH Mood Stabilizer Medication" using "BH Mood Stabilizer Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.950)"- "Medication, Order: BH Antidepressant Medication" using "BH Antidepressant Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.972)"- "Medication, Order: BH Mood Stabilizer Medication" using "BH Mood Stabilizer Medication Grouping Value Set (2.16.840.1.113883.3.1257.1.950)"- "Procedure, Order: BH Counseling for Depression" using "BH Counseling for Depression Grouping Value Set (2.16.840.1.113883.3.1257.1.1616)"- "Procedure, Order: BH Electroconvulsive Therapy" using "BH Electroconvulsive Therapy Grouping Value Set (2.16.840.1.113883.3.1257.1.1533)"- "Procedure, Performed: BH Assessment for Alcohol or Other Drugs" using "BH Assessment for Alcohol or Other Drugs Grouping Value Set (2.16.840.1.113883.3.1257.1.1604)"- "Procedure, Performed: BH Counseling for Depression" using "BH Counseling for Depression Grouping Value Set (2.16.840.1.113883.3.1257.1.1616)"- "Procedure, Performed: BH Electroconvulsive Therapy" using "BH Electroconvulsive Therapy Grouping Value Set (2.16.840.1.113883.3.1257.1.1533)" Supplemental Data Elements:- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"- "Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"- "Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeGender Value Set (2.16.840.1.113762.1.4.1)"H2-510: Reduce Rate of 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 conditionsH2-510: Reduce Rate of Emergency Department visits for Behavioral Health and Substance Abuse (Reported as two rates)DY7/DY8 Program IDH2-510Measure DetailsSteward: NANQF #: NASource: NAData SourceClaimsRequired StatusRequired as P4P for MPT of 75, optional as P4P with additional points for MPT below 75 or P4R for any provider with greater than 0 numerator volumeMeasure ClassificationType: Population Based Clinical OutcomeMeasure Parts: 2Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: IndividualsMeasure will be reported for all-payer, medicaid, and uninsured with P4P based on the combined medicaid an uninsured rate. No payer-type exceptions are allowed. .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 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 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.Bundle H3 Chronic Non-Malignant Pain ManagementMeasure Bundle ObjectivesImprove individuals' quality of life and reduce pain through lifestyle modification, psychological approaches, interventional pain management, and/or pharmacotherapy while recognizing current or potential substance abuse disorders. Improve providers’ ability to identify and manage chronic non-malignant pain using a function-based multimodal approach, and ability to screen for substance use disorder and connect individuals to appropriate treatment.Target PopulationIndividuals in the DSRIP attributed population with one or more of the following: a. A diagnosis of chronic pain ORb. Acute pain prescribed an opioid for longer than six weeks during the measurement year.Related System ComponentsPrimary Care, Outpatient Specialty CareNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoH3-144: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) for individuals with a diagnosis of chronic painMeasure Description:Percentage of patients aged 12 years and older with a diagnosis of moderate to severe chronic pain screened for clinical depression using an age appropriate standardized tool AND follow-up plan documentedH3-144: Screening for Clinical Depression and Follow-Up Plan (CDF-AD) for individuals with a diagnosis of chronic painDY7/DY8 Program IDH3-144Measure DetailsSteward: CMSNQF #: 0418Source: CMS MIPS #134 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 years and olderDenominator InclusionsCLAIMS/REGISTRY: Patients aged ≥ 12 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0101, G0402, G0438, G0439, G0444 E.H.R.: AND: Age>= 12 year(s) at: "Measurement Period" AND: "Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY: Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required: G9717ORScreening for depression not completed, documented reason (G8433) E.H.R.: OR: "Diagnosis: Depression diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) OR: "Diagnosis: Bipolar Diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" )Numerator DescriptionPatients screened for depression on the date of the encounter using an age appropriate standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screenNumerator Instructions: The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. The depression screening must be reviewed and addressed in the office of the provider filing the code on the date of the encounter. Definitions:Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to:? Adolescent Screening Tools (12-17 years):Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric Symptom Checklist (PSC-17), and PRIME MD-PHQ2 ? Adult Screening Tools (18 years and older)Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2 Follow-Up Plan – Documented follow-up for a positive depression screening must include one or more of the following:? Additional evaluation for depression? Suicide Risk Assessment? Referral to a practitioner who is qualified to diagnose and treat depression? Pharmacological interventions? Other interventions or follow-up for the diagnosis or treatment of depressionNot Eligible for Depression Screening or Follow-Up Plan –? Patient has an active diagnosis of Depression? Patient has a diagnosed Bipolar DisorderPatients with a Documented Reason for not Screening for Depression –One or more of the following conditions are documented:? Patient refuses to participate? Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status? Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of deliriumNumerator Inclusions (Performance Met)CLAIMS/REGISTRY: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)ORScreening for depression is documented as negative, a follow-up plan is not required (G8510) E.H.R.: AND: OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Negative Depression Screening)" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adolescent" "Intervention, Order: Referral for Depression Adolescent" "Medication, Order: Depression medications - adolescent" "Intervention, Performed: Follow-up for depression - adolescent" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adolescent Depression Screening" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Negative Depression Screening)" AND: Age>= 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adult" "Intervention, Order: Referral for Depression Adult" "Medication, Order: Depression medications - adult" "Intervention, Performed: Follow-up for depression - adult" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adult Depression Screening" AND: Age>= 18 year(s) at: "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Depression screening not documented, reason not given (G8432)ORScreening for depression documented as positive, follow-up plan not documented, reason not given (G8511) E.H.R.:NoneDSRIP Specific ModificationsNote: For DSRIP reporting purposes, this measure should be subsetted to individuals with a diagnosis of moderate to severe chronic pain using the inclusion criteria of H3-T05. The specifications as written do not include this subset.Additional InformationData Criteria (QDM Data Elements):? "Diagnosis: Bipolar Diagnosis" using "Bipolar Diagnosis Grouping Value Set (2.16.840.1.113883.3.600.450)"? "Diagnosis: Depression diagnosis" using "Depression diagnosis Grouping Value Set (2.16.840.1.113883.3.600.145)"? "Encounter, Performed: Depression Screening Encounter Codes" using "Depression Screening Encounter Codes Grouping Value Set (2.16.840.1.113883.3.600.1916)"? "Intervention, Order: Referral for Depression Adolescent" using "Referral for Depression Adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.537)"? "Intervention, Order: Referral for Depression Adult" using "Referral for Depression Adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.538)"? "Intervention, Performed: Additional evaluation for depression - adolescent" using "Additional evaluation for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.1542)"? "Intervention, Performed: Additional evaluation for depression - adult" using "Additional evaluation for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.1545)"? "Intervention, Performed: Follow-up for depression - adolescent" using "Follow-up for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.467)"? "Intervention, Performed: Follow-up for depression - adult" using "Follow-up for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.468)"? "Medication, Order: Depression medications - adolescent" using "Depression medications - adolescent RXNORM Value Set (2.16.840.1.113883.3.600.469)"? "Medication, Order: Depression medications - adult" using "Depression medications - adult RXNORM Value Set (2.16.840.1.113883.3.600.470)"? "Procedure, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment SNOMEDCT Value Set (2.16.840.1.113883.3.600.559)"? "Risk Category Assessment: Adolescent Depression Screening" using "Adolescent Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2452)"? "Risk Category Assessment: Adult Depression Screening" using "Adult Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2449)"? "Risk Category Assessment 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)"? "Risk Category Assessment not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Result: Negative Depression Screening" using "Negative Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2451)"? Attribute: "Result: Positive Depression Screening" using "Positive Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2450)"H3-287: Documentation of Current Medications in the Medical RecordMeasure Description:Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administrationH3-287: Documentation of Current Medications in the Medical RecordDY7/DY8 Program IDH3-287Measure DetailsSteward: CMSNQF #: 0419Source: CMS MIPS #130 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll visits for patients aged 18 years and olderDenominator InclusionsCLAIMS/REGISTRY:Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439 E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: Medications Encounter Code Set" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY:Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician (G8430) E.H.R.:None Denominator Exceptions = OR: "Procedure, Performed not done: Medical or Other reason not done" for "Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"Numerator DescriptionEligible clinician attests to documenting, updating or reviewing a patient’s current medications using all resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administrationDefinitions: Current Medications – Medications the patient is presently taking including all prescriptions, over-the- counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.Route – Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical) Not Eligible (Denominator Exception) – A patient is not eligible if the following reason is documented:?Patient is in an urgent or emergent medical situation where time is of the essence and to delaytreatment would jeopardize the patient’s health status NUMERATOR NOTE: The eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible clinician documented that the patient is not currently taking any medicationsNumerator Inclusions (Performance Met)CLAIMS/REGISTRY:Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications (G8427) E.H.R.: AND: "Procedure, Performed: Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given (G8428) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationE.H.R.:Data Criteria (QDM Data Elements):? "Encounter, Performed: Medications Encounter Code Set" using "Medications Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1834)"? "Procedure, Performed: Current Medications Documented SNMD" using "Current Medications Documented SNMD SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.462)"? "Procedure, 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)"H3-288: Pain Assessment and Follow-upMeasure Description:Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is presentH3-288: Pain Assessment and Follow-upDY7/DY8 Program IDH3-288Measure DetailsSteward: CMSNQF #: 0420Source: CMS MIPS #131 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll visits for patients aged 18 years and olderDenominator InclusionsPatients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 98940, 98941, 98942, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, D7140, D7210, G0101, G0402, G0438, G0439 WITHOUT Telehealth Modifier: GQ, GTDenominator ExclusionsPain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool (G8442)ORPain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible (G8939)Numerator DescriptionPatient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present Pain Assessment – Documentation of a clinical assessment for the presence or absence of pain using a standardized tool is required. A multi-dimensional clinical assessment of pain using a standardized tool may include characteristics of pain; such as: location, intensity, description, and onset/duration.Standardized Tool – An assessment tool that has been appropriately normed and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS) and Visual Analog Scale (VAS), Patient-Reported Outcomes Measurement Information System (PROMIS).Follow-Up Plan – A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable OR indicate the initial treatment plan is still in effect. These plans may include pharmacologic, behavioral, physical medicine and/or educational interventions. Not Eligible (Denominator Exception) – A patient is not eligible if one or more of the following reason(s) is documented:?Severe mental and/or physical incapacity where the person is unable to express himself/herself in amanner understood by others. For example, cases where pain cannot be accurately assessed throughuse of nationally recognized standardized pain assessment tools?Patient is in an urgent or emergent situation where time is of the essence and to delay treatment wouldjeopardize the patient’s health status NUMERATOR NOTE: The standardized tool used to assess the patient’s pain must be documented in the medical record (exception: A provider may use a fraction such as 5/10 for Numeric Rating Scale without documenting this actual tool name when assessing pain for intensity).Numerator Inclusions (Performance Met)Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented (G8730)ORPain assessment using a standardized tool is documented as negative, no follow-up plan required (G8731)Numerator Exclusions (Performance Not Met)No documentation of pain assessment, reason not given (G8732)ORPain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given (G8509)DSRIP Specific ModificationsNoneAdditional InformationNoneH3-401: Opioid Therapy Follow-up EvaluationMeasure Description:All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record. NOTE: Include only patients that have 6 weeks opioid use through September 30 of the performance period. This will allow the follow-up evaluation of at least 90 days after opioid therapy within the reporting year.H3-401: Opioid Therapy Follow-up EvaluationDY7/DY8 Program IDH3-401Measure DetailsSteward: American Academy of NeurologyNQF #: NASource: CMS MIPS #408 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure 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 18 and older prescribed opiates for longer than six weeks durationDenominator InclusionsPatients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 WITHOUT Telehealth Modifier: GQ, GT AND Patients prescribed opiates for longer than six weeks: G9561Denominator ExclusionsNANumerator DescriptionPatients who had a follow-up evaluation conducted at least every three months during opioidtherapyNumerator Inclusions (Performance Met)Patients who had a follow-up evaluation conducted at least every three months during opioid therapy (G9562)Numerator Exclusions (Performance Not Met)Patients who did not have a follow-up evaluation conducted at least every three months during opioid therapy (G9563)DSRIP Specific ModificationsNoneAdditional InformationNoneH3-403: Evaluation or Interview for Risk of Opioid MisuseMeasure Description:All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical recordH3-403: Evaluation or Interview for Risk of Opioid MisuseDY7/DY8 Program IDH3-403Measure DetailsSteward: American Academy of NeurologyNQF #: NASource: CMS MIPS #414 (Claims/Registry)Data SourceClaimsRequired StatusRequiredMeasure 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 18 and older prescribed opiates for longer than six weeksdurationDenominator InclusionsPatients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 WITHOUT Telehealth Modifier: GQ, GT AND Patients prescribed opiates for longer than six weeks: G9583Denominator ExclusionsNANumerator DescriptionPatients evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool,Opioid Assessment for Patients with Pain, revised (SOAPP-R)) or patient interview at least once during opioid therapyNumerator Inclusions (Performance Met)Patient evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAPP-R) or patient interviewed at least once during opioid therapy (G9584)Numerator Exclusions (Performance Not Met)Patient not evaluated for risk of misuse of opiates by using a brief validated instrument (e.g., Opioid Risk Tool, SOAPP-R) or patient not interviewed at least once during opioid therapy (G9585)DSRIP Specific ModificationsNoneAdditional InformationNoneH3-T05: Innovative Measure: Treatment of Chronic Non-Malignant PainMeasure Description:Percentage of patients diagnosed with moderate to severe chronic pain who are provided non-opioid pain management strategies. Non-opioid pain management strategies can include prescriptions for non-opioid medications for pain, referrals to physical/occupational therapy, referrals to psychosocial counseling, education about self-management of pain, provision of pain management procedures or surgeries, or any of the other pain management modalities listed in the “definitions” section below.H3-T05: Innovative Measure: Treatment of Chronic Non-Malignant PainDY7/DY8 Program IDH3-T05Measure DetailsSteward: San Francisco Health Network, Alameda Health Systems, UC San DiegoNQF #: NASource: NAData SourceAnyRequired StatusOptional Innovative MeasureMeasure ClassificationType: InnovativeMeasure Parts: 1Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit 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 DescriptionIndividuals who meet the following criteria: a. Have a diagnosis of moderate to severe pain that has lasted at least 90 days and that exists as of the last day of the measurement period. The 90 day criteria can be met at any point during the measurement period.b. AND do not have cancerc. AND are not enrolled in hospiced. AND are not receiving palliative care servicesA diagnosis of moderate to severe chronic pain can be identified using any of the following:? ICD-10 codes: R52.1, R52.2, G89.21, G89.22, G89.28, G89.29, or G89.4 Z79.891? Presence on a chronic pain registryIt is not recommend that providers use anatomically specific pain codes, e.g. low back pain, knee pain, etc. because they are often used to denote more mild pain and possibly acute pain. If health systems are confident that their providers are using specific local pain ICD10 codes to describe chronic pain, then those health systems can use those specific codes to generate a chronic pain registry.Cancer/Hospice/Palliative Care exclusions are identified as follows:? Cancer: Table OHD-B. ICD-10 Diagnosis Codes for Cancer (Exclusions), available at: ? “Enrolled in Hospice” using (Hospice Value Set)Denominator InclusionsDefinitions as applicableNon-opioid approaches to chronic pain include: ? Medication Optionso Anti-epileptic medications (Examples: Carbamazepine, Gabapentin, Lamotrigine, Oxcarbazepine, Pregabalin, Topiramate)o SNRI antidepressants (Examples: Venlafaxine, Duloxetine)o Tricyclic antidepressants (Examples: Amitriptyline, Desipramine, Dozepine, Imipramine, Nortriptyline, Clomipramine, Maprotilinne, Trimipramine, Protriptyline)o NSAIDs and Acetaminophen (Examples: Acetaminophen, Aspirin, Celecoxib, Diclofenac, Etodolac, Ibuprofen, Indomethacin, Ketoprofen, Ketorolac, Nabumetone, Naproxen, Oxaprozin, Piroxicam, Salsalate, Sulindac, Tolmetin)o Topical treatments (Examples: Lidocaine gel or patch, Capsaicin cream, Diclofenac cream) o Intrathecal drug delivery? Non-Pharmacologic Optionso Procedures (Examples: Steroid injection (joint, epidural), Trigger point injection, Surgical intervention, Nerve blocks and nerve ablation, Nerve stimulation, including TENS and central stimulation techniques)o Self-Care (Examples: Ice, Heat, Compression, Exercise, Pacing strategies (time based or pain based pacing education))o Movement based (Examples: Physical therapy, Occupational therapy, Aquatic therapy, Supervised physical activity, Yoga, Tai Chi, Qi Gong)o Behavioral and Psychological (Examples: Individual psychotherapy (CBT based, ACT base, psychodynamic, family, or other models), Group therapy (including self-management education, cognitive behavioral therapy, acceptance and commitment therapy, or others), Neuroscience education, Support groups, Participation in online therapy for pain management, Deep Breathing, Biofeedback, Progressive muscle relaxation/body scans, Hypnosis, Guided imagery/guided meditation, Online relaxation resources or apps for meditation, guided imagery, breathing, etc.)? Complementary and Alternative (Examples: Acupuncture, Massage, Mindfulness, meditation/Mindfulness Based Stress Reduction, Herbal therapies or supplements)Other Notes as applicablePatients in the numerator include all patients who have been provided resources to promote non-opioid pain management, including prescriptions, referrals, or education. It is not required that patients take up the referral, prescription, or self-management practice. This metric can be monitored by directly searching for referrals, prescriptions, and documentation of education. Alternatively, clinics may choose to create an electronic checklist in their chronic pain template that allows providers to check off non-opioid therapies that they have tried with a patient, allowing for simple tracking of this metric in an EMR. Denominator ExclusionsNANumerator DescriptionIndividuals from the denominator who have received a recommendation, education about, prescription for, or referral to, non-opioid pain management in the outpatient setting. This recommendation, referral, or prescription can come at any point during the measurement period and from any member of the healthcare team. Numerator Code/s (CPT, ICD10, other): Per local tracking by Texas DSRIP provider. Any of the following during the measurement period:- OR “Referred to physical therapy”- OR “Referred to occupational therapy”- OR “Referred to surgery”- OR “Referred to interventional pain clinic”- OR “Referred to behavioral medicine”- OR “Referred to chronic pain group”- OR “Referred to aquatic therapy”- OR “Referred to exercise class”- OR “Referred to yoga class”- OR “Referred to Tai Chi class”- OR “Referred to Qi Gong class”- OR “Referred to online pain management resource”-OR: “Prescribed” ? OR: Carbamazepine ? OR: Gabapentin ? OR: Lamotrigine ? OR: Oxcarbazepine ? OR: Pregabalin ? OR: Topiramate ? OR: Venlafaxine ? OR: Duloxetine ? OR: Amitriptyline ? OR: Desipramine ? OR: Dozepine ? OR: Imipramine ? OR: Nortriptyline ? OR: Clomipramine ? OR: Maprotilinne ? OR: Trimipramine ? OR: Protriptyline ? OR: Acetaminophen ? OR: Aspirin ? OR: Celecoxib ? OR: Diclofenac ? OR: Etodolac ? OR: Ibuprofen ? OR: Indomethacin ? OR: Ketoprofen ? OR: Ketorolac ? OR: Nabumetone ? OR: Naproxen ? OR: Oxaprozin ? OR: Piroxicam ? OR: Salsalate ? OR: Sulindac ? OR: Tolmetin ? OR: Lidocaine gel or patch ? OR: Capsaicin cream ? OR: Diclofenac cream ? OR: TENS unit ? OR: Compression device- OR: Procedure, performed “Steroid injection”- OR: Procedure, performed “Trigger point injection”- OR: Education provided ? OR: Heat and Ice for pain ? OR: Exercise ? OR: Pacing strategies for pain management ? OR: Neuroscience education ? OR: Deep breathing ? OR: Progressive muscle relaxation ? OR: Body Scan ? OR: Guided imagery- OR “Referred to biofeedback”- OR “Referred to hypnosis”- OR “Referred to online mind-body resources”- OR “Referred to Mindfulness meditation class”- OR “Referred to Mindfulness Based Stress Reduction class”- OR “Referred to acupuncture”- OR “Referred to massage”- OR “Recommended Herbal therapy or supplement”Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneH3-T06: Innovative Measure: Patients on long-term opioid therapy checked in prescription drug monitoring programs (PDMPs)Measure Description:In order to minimize the risk of opioid prescribing by multiple prescribers, a statewide Prescription Drug Monitoring Program (PDMP) should be checked at least annually for every patient with chronic pain on long term opioid therapy.H3-T06: Innovative Measure: Patients on long-term opioid therapy checked in prescription drug monitoring programs (PDMPs)DY7/DY8 Program IDH3-T06Measure DetailsSteward: AHRQ/San Francisco Health Network, Alameda Health Systems, UC San DiegoNQF #: NASource: NAData SourceAnyRequired StatusOptional Innovative MeasureMeasure ClassificationType: InnovativeMeasure Parts: 1Achievement CalculationsCategory: P4RGoal Calculation: NAHPL: NAMPL: NANADirectionality: NAUnit 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 DescriptionIndividuals who meet the following criteria: a. Have a diagnosis of moderate to severe pain that has lasted at least 90 days and that exists as of the last day of the measurement period. The 90 day criteria can be met at any point during the measurement period.b. AND do not have cancerc. AND are not enrolled in hospiced. AND are not receiving palliative care services? "Medication, Active: Long term use of opiate analgesic” o ICD-10 code: Z79.891A diagnosis of moderate to severe chronic pain can be identified using any of the following:? ICD-10 codes: R52.1, R52.2, G89.21, G89.22, G89.28, G89.29, or G89.4 Z79.891? Presence on a chronic pain registryIt is not recommend that providers use anatomically specific pain codes, e.g. low back pain, knee pain, etc. because they are often used to denote more mild pain and possibly acute pain. If health systems are confident that their providers are using specific local pain ICD10 codes to describe chronic pain, then those health systems can use those specific codes to generate a chronic pain registry.Cancer/Hospice/Palliative Care exclusions are identified as follows:? Cancer: Table OHD-B. ICD-10 Diagnosis Codes for Cancer (Exclusions), available at: ? “Enrolled in Hospice” using (Hospice Value Set)Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionPatients who have notation in the medical record that PDMP was reviewed < 1 year prior to the last date of the measurement period. Tracking may be achieved through local coding by Texas DSRIP entity, manual chart review, registry report, EHR keyword search (e.g, for “PDMP” or “Prescription Drug Monitoring Program” or “CURES Report”), or other locally determined mechanism.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneBundle H4 Integrated Care for People with Serious Mental IllnessMeasure Bundle ObjectivesImprove physical health outcomes for individuals with serious mental illness.Target PopulationIndividuals included in the DSRIP attributed population with a diagnosis of serious mental Illness (bipolar, schizophrenia & schizoaffective disorders, MDD)Related System ComponentsPrimary Care, Relevant Outpatient Specialty CareNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoH4-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD)Measure Description:The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were prescribed an antipsychotic medication and had a diabetes screening test during the measurement year.H4-182: Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD)DY7/DY8 Program IDH4-182Measure DetailsSteward: NCQANQF #: 1932Source: CMS Adult Core SetData SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.8717MPL: 0.7737National 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 84.01% and DY8 goal of 84.33%.Denominator DescriptionPatients ages 18 to 64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication.Denominator InclusionsAges 18 to 64 as of December 31 of the measurement year.ANDAt least one of the following criteria during the mesaurement year: - At least one acute inpatient encounter with any diagnosis of schizophrenia or bipolar disorder. Any of the following code combinations meet criteria: - BH Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set - BH Stand Alone Acute Inpatient Value Set with Bipolar Disorder Value Set - BH Stand Alone Acute Inpatient Value Set with Other Bipolar Disorder Value Set - BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Schizophrenia Value Set - BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Bipolar Disorder Value Set - BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Other Bipolar Disorder Value Set- At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED, or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia. Any two of the following code combinations meet criteria: - BH Stand Alone Outpatient/PH/IOP Value Set with Schizophrenia Value Set - BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Schizophrenia Value Set - ED Value Set with Schizophrenia Value Set - BH ED Value Set with ED POS Value Set and Schizophrenia Value Set - BH Stand Alone Nonacute Inpatient Value Set with Schizophrenia Value Set - BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Schizophrenia Value Set- At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED, or nonacute inpatient setting, on different dates of service, with any diagnosis of bipolar disorder. Any two of the following code combinations meet criteria: - BH Stand Alone Outpatient/PH/IOP Value Set with Bipolar Disorder Value Set - BH Stand Alone Outpatient/PH/IOP Value Set with Other Bipolar Disorder Value Set - BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Bipolar Disorder Value Set - BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Other Bipolar Disorder Value Set - ED Value Set with Bipolar Disorder Value Set - ED Value Set with Other Bipolar Disorder Value Set - BH ED Value Set with ED POS Value Set and Bipolar Disorder Value Set - BH ED Value Set with ED POS Value Set and Other Bipolar Disorder Value Set - BH Stand Alone Nonacute Inpatient Value Set with Bipolar Disorder Value Set - BH Stand Alone Nonacute Inpatient Value Set with Other Bipolar Disorder Value Set - BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Bipolar Disorder Value Set - BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Other Bipolar Disorder Value Set AbilifyAbilify DiscmeltAbilify MaintenaAripiprazoleAristadaChlorpromazine HydrochlorideClozapineClozarilCompazineFanaptFazaCloFluoxetine Hydrochloride-OlanzapineFluphenazine DecanoateFluphenazine HydrochlorideGeodonHaldol DecanoateHaloperidolHaloperidol DecanoateHaloperidol LactateInvegaInvega SustennaInvega TrinzaLatudaLoxapine SuccinateLoxitaneMolindone HydrochlorideOlanzapineOrapPaliperidone ERPermitilPerphenazinePerphenazine-AmitriptylinePimozideProchlorperazine MaleateQuetiapine FumarateRexultiRisperdalRisperdal ConstaRisperdal M-TabRisperidoneSaphrisSaphris Black CherrySeroquelSeroquel XRSymbyaxThioridazine HydrochlorideThiothixeneTrifluoperazine HydrochlorideTrilafonVersaclozVraylarZiprasidone HydrochlorideZyprexaZyprexa RelprevvZyprexa ZydisDenominator ExclusionsStep 2: Required ExclusionsExclude patients who met any of the following criteria: Patients with diabetes:There are two ways to identify beneficiaries with diabetes: (1) by claims/encounter data and (2) by pharmacy data. Providers should use both methods to identify beneficiaries with diabetes, but a beneficiary need only be identified by one method to be excluded from the measure. Patients may be identified as having diabetes during the measurement year or the year prior to the measurement year.1. Claims/encounter data. Beneficiaries who met any of the following criteria during the measurement year or year prior to the measurement year (count services that occur over both years): ? At least two outpatient visits Outpatient Value Set), observation visits (Observation Value Set), ED Visits (ED Value Set), or nonacute inpatient encounters (Nonacute Inpatient Value Set) on different dates of service, with a diagnosis of diabetes (Diabetes Value Set). Visit type need not be the same for the two visits. services that occur over both years): ? At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of diabetes (Diabetes Value Set).2. Pharmacy data. Beneficiaries who were dispensed insulin or oral hypoglycemics/ antihyperglycemics during the measurement year or the year prior to the measurement year (Table SSD-A)Prescriptions to Identify Beneficiaries with Diabetes:Alpha-glucosidase inhibitors:- Acarbose- MiglitolAmylin analogs: - PramlinitideAntidiabetic combinations:- Alogliptin-metformin- Alogliptin-pioglitazone- Canaglifozin-metformin- Dapagliflozin-metformin- Empaglifozin-linagliptin- Empagliflozin/metformin- Glimepiride-pioglitazone- Glimepiride-rosiglitazone- Glipizide-metformin- Glyburide-metformin- Linagliptin-metformin- Metformin-pioglitazone- Metformin-repaglinide- Metformin-rosiglitazone- Metformin-saxagliptin- Metformin-sitagliptin- Sitagliptin-simvastatinInsulin: - Insulin aspart- Insulin aspart-insulin aspart protamine- Insulin degludec- Insulin detemir- Insulin glargine- Insulin glulisine- Insulin human inhaled- Insulin isophane human- Insulin isophane-insulin regular- Insulin lispro- Insulin lispro-insulin lispro protamine- Insulin regular human- Meglitinides: - Nateglinide- RepaglinideGlucagon-like peptide-1 (GLP1) agonists:- Dulaglutide- Exenatide- Liraglutide- AlbiglutideSodium glucose cotransporter 2 (SGLT2) inhibitor:- Canagliflozin- Dapagliflozin- EmpagliflozinSulfonylureas: - Chlorpropamide- Glimepiride- Glipizide- Glyburide- Tolazamide- TolbutamideThiazolidinediones: - Pioglitazone- RosiglitazoneDipeptidyl peptidase-4 (DDP-4) inhibitors:- Alogliptin- Linagliptin- Saxagliptin- Sitaglipin Beneficiaries who had no antipsychotic medications dispensed during the measurement year:There are two ways to identify dispensing events: (1) by claims/encounter data and (2) by pharmacy data. Both methods must be used to identify dispensing events, but an event need only be identified by one method to be counted.1. Claim/encounter data. An antipsychotic medication (Long-Acting Injections Value Set).2. Pharmacy data. Dispensed an antipsychotic medication (Table SSD-B) on an ambulatory basis:Miscellaneous antipsychotic agents (oral):- Aripiprazole- Asenapine- Brexpiprazole- Cariprazine- Clozapine- Haloperidol- Iloperidone Loxapine- Lurasidone- Molindone- Olanzapine- Paliperidone- Pimozide- Quetiapine- Quetiapinefumarate- Risperidone- Ziprasidone- Phenothiazine antipsychotics (oral):- Chlorpromazine- Fluphenazine- Perphenazine- Perphenazineamitriptyline- Prochlorperazine- Thioridazine- TrifluoperazinePsychotherapeutic combinations (oral):- Fluoxetine-olanzapineThioxanthenes (oral):- ThiothixeneLong-acting injections: - Aripiprazole- Fluphenazine- decanoate- Haloperidol decanoate- Olanzapine- Paliperidone- palmitate- Risperidone Exclude members who use hospice services or elect to use a hospice benefit any time during the measurement year, regardless of when the services began.Numerator DescriptionA glucose test (Glucose Tests Value Set) or an HbA1c test (HbA1c Tests Value Set) performed during the measurement year, as identified by claims/encounter or automated laboratory data.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsSource measure was specified at the health plan level. Measure has been adapted from the 2017 CMS Adult Core Set and has been respecified to refer to patients rather than members, and to refer to medications prescribed rather than medications dispensed.Additional InformationRefer to HEDIS 2017 Value Set Directory for referenced value sets.H4-258: Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC)Measure Description:The percentage of patients 18 – 64 years of age with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year.H4-258: Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC)DY7/DY8 Program IDH4-258Measure DetailsSteward: NCQANQF #: 1933Source: SAMHSA CCBHC State Reported MeasuresData SourceClaims, E.H.R. Required StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: QISMCHPL: 0.8837MPL: 0.7353National 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 83.64% and DY8 goal of 84.11%.Denominator DescriptionPatients 18-64 years of age as of the end of the measurement year with a diagnosis of schizophrenia and cardiovascular disease.Denominator InclusionsFollow the steps below to identify the eligible population. Step 1: Identify patients with schizophrenia as those who met at least one of the following criteria during the measurement year: At least one acute inpatient encounter with any diagnosis of schizophrenia. Either of the following code combinations meets criteria: – BH Stand Alone Acute Inpatient Value Set with Schizophrenia Value Set. – BH Acute Inpatient Value Set with BH Acute Inpatient POS Value Set and Schizophrenia Value Set. At least two visits in an outpatient, intensive outpatient, partial hospitalization, ED or nonacute inpatient setting, on different dates of service, with any diagnosis of schizophrenia. Any two of the following code combinations meet criteria: – BH Stand Alone Outpatient/PH/IOP Value Set with Schizophrenia Value Set. – BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Schizophrenia Value Set. – ED Value Set with Schizophrenia Value Set. – BH ED Value Set with BH ED POS Value Set and Schizophrenia Value Set. – BH Stand Alone Nonacute Inpatient Value Set with Schizophrenia Value Set. – BH Nonacute Inpatient Value Set with BH Nonacute Inpatient POS Value Set and Schizophrenia Value Set. – BH Outpatient/PH/IOP Value Set with BH Outpatient/PH/IOP POS Value Set and Schizophrenia Value Set Step 2: Identify patients from step 1 who also have cardiovascular disease. Patients are identified as having cardiovascular disease in two ways: by event or by diagnosis. The organization must use both methods to identify the eligible population, but a patient need only be identified by one to be included in the measure. Event: Any of the following during the year prior to the measurement year meet criteria: - AMI. Discharged from an inpatient setting with an AMI (AMI Value Set). Use both facility and professional claims to identify AMI. - CABG. Discharged from an inpatient setting with a CABG (CABG Value Set). Use both facility and professional claims to identify CABG. - PCI. Patients who had PCI (PCI Value Set) in any setting (e.g., inpatient, outpatient, ED). Diagnosis: Identify patients with IVD as those who met at least either of the following criteria during both the measurement year and the year prior to the measurement year. Criteria need not be the same across both years. - At least one outpatient visit (Outpatient Value Set) with a diagnosis of IVD (IVD Value Set). - At least one acute inpatient encounter (Acute Inpatient Value Set) with a diagnosis of IVD (IVD Value Set).Denominator ExclusionsNot applicable.Numerator DescriptionIndividuals from the denominator with one or more LDL-C tests performed during the measurement year.Numerator Inclusions (Performance Met)An LDL-C test (LDL-C Tests Value Set) performed during the measurement year, as identified by claim/encounter or automated laboratory data.The organization may use a calculated or direct LDL.Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsHHSC added the following eligibility criteria to this measure to align the definition of individuals with schizophrenia with measure H4-182 Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AAdditional InformationRefer to 2017 Adult Core Set HEDIS Value Set Directory for referenced value sets.H4-260: Annual Physical Exam for Persons with Mental IllnessMeasure Description:The percentage of individuals receiving services for a primary psychiatric disorder whose medical records document receipt of a physical exam during the measurement year.H4-260: Annual Physical Exam for Persons with Mental IllnessDY7/DY8 Program IDH4-260Measure DetailsSteward: Center for Quality Assessment and Improvement in Mental Health (CQAIMH)NQF #: NASource: SourceClaimsRequired StatusRequiredMeasure 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 DescriptionThe total number of individuals receiving services for a primary psychiatric disorder during a specified 12- month reporting period.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsNone listed by measure steward.Numerator DescriptionIndividuals from the denominator whose medical record documents receipt of a physical examination within the specified 12-month period.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationNoneBundle I1 Specialty CareMeasure Bundle ObjectivesImprove quality of life and functional status for individuals with chronic and life impacting conditions receiving services in an outpatient specialty care setting.Target PopulationDSRIP attributed individuals with a chronic conditions receiving services in an outpatient specialty care settingRelated System ComponentsSpecialty Care (Prior Authorization Required)NOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNAMeasures Hospital BasedServicesNAI1-385: Assessment of Functional Status or QoL Measure Description:Percent of eligible patients who completed a health-related quality of life assessment or functional assessment using a standardized tool at least once during the measurement period.I1-385: Assessment of Functional Status or QoL DY7/DY8 Program IDI1-385Measure DetailsSteward: NANQF #: NASource: NA (Modified from NQF# 0260/2624)Data SourceAnyRequired StatusRequired - prior authorization required for selectionMeasure ClassificationType: Quality of LifeMeasure 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 eligible individuals receiving specialty care services during the measurement periodDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionNumber of eligible patients who completed a health-related quality of life assessment or functional assessment using a standardized tool at least once during the measurement period.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationIf 385 and 386 are selected, the same tools must be used in both measures. Provider to specify Functional Status or QoL instrument during RHP plan submission. Instrument must be externally validated and tested for reliability and used for assessment of improvements status. Approvable instruments include (not exhaustive):- AQoL-4D, 6D, 7D, and 8D- PedsQL, including disease specific modules- SF-12, SF-36- Palliative Care Outcome Scale- Fact G- BDI-2- PAID Excluded instruments include:- ANSA- CANS- HRQoL- ABCI1-386: Improvement in Functional Status or QoL (Modified from PQRS #435)Measure Description:Percent of patients who had a follow up health-related quality of life or functional status assessed during the measurement period whose score stayed the same or improved.I1-386: Improvement in Functional Status or QoL (Modified from PQRS #435)DY7/DY8 Program IDI1-386Measure DetailsSteward: NANQF #: NASource: NAData SourceAnyRequired StatusRequired - prior authorization required for selectionMeasure ClassificationType: Quality of LifeMeasure 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 who had a follow up health-related quality of life or functional status assessed during the measurement periodDenominator InclusionsNADenominator ExclusionsNANumerator DescriptionPatients whose score stayed the same or improved.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationIf 385 and 386 are selected, the same tools must be used in both measures. Provider to specify Functional Status or QoL instrument during RHP plan submission. Instrument must be externally validated and tested for reliability and used for assessment of improvements status. Approvable instruments include (not exhaustive):- AQoL-4D, 6D, 7D, and 8D- PedsQL, including disease specific modules- SF-12, SF-36- Palliative Care Outcome Scale- Fact G- BDI-2- PAID Excluded instruments include:- ANSA- CANS- HRQoL- ABCBundle J1 Hospital SafetyMeasure Bundle ObjectivesImprove patient health outcomes and experience of care by improving medication management, reducing the risk of health-care associated infections, and reducing hospital errors.Target PopulationIndividuals receiving inpatient care Related System ComponentsHospitalNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNoMeasures Hospital BasedServicesYesJ1-218: Central line-associated Bloodstream Infection (CLABSI) Measure Description:Standardized Infection Ratio (SIR) of healthcare-associated, central line-associated bloodstream infections (CLABSI) will be calculated among patients in bedded inpatient care locations. This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavioral health hospitals.J1-218: Central line-associated Bloodstream Infection (CLABSI) DY7/DY8 Program IDJ1-218Measure DetailsSteward: CDCNQF #: 0139 Source: SourceNHSN ReportRequired StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of predicted healthcare-associated CLABSI among patients in bedded inpatient care locations, calculated using the facility’s number of central line days and the following significant risk factors:? Acute Care Hospitals: CDC location, facility bedsize, medical school affiliation, facility type, birthweight category (NICU locations only)? Critical Access Hospitals: no significant risk factors, calculation based on pooled mean rate? Inpatient Rehabilitation Facilities: no significant risk factors, calculation based on pooled mean rate? Long Term Acute Care Hospitals: CDC location, facility bedsize, average length of stayDenominator InclusionsNone listed by measure steward.Denominator ExclusionsThe following devices are excluded as central lines:o Pacemaker wires and other non-lumened devices inserted into central blood vessels or the hearto Arterial catheterso Arteriovenous fistulao Arteriovenous grafto Extracorporeal membrane oxygenation (ECMO)o Hemodialysis reliable outflow (HERO) dialysis catheterso Intra-aortic balloon pump (IABP) deviceso Non-accessed central line (not accessed nor inserted during the hospitalization)o Peripheral IV or Midlineso Ventricular Assist Device (VAD)Numerator DescriptionTotal number of observed healthcare-associated CLABSI among patients in bedded inpatient care locations.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationCLABSI and central line device days must be collected by trained hospital staff from information available in clinical data sources. The standard population’s CLABSI rates are available from the NHSN Report. The NHSN analysis tool will automatically calculate SIRs. Some of the data used in the measure can be mined from electronic data sources. J1-219: Catheter-associated Urinary Tract Infection (CAUTI) Measure Description:Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU). This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.J1-219: Catheter-associated Urinary Tract Infection (CAUTI) DY7/DY8 Program IDJ1-219Measure DetailsSteward: CDCNQF #: 0138 (updated January, 2018)Source: SourceNHSN ReportRequired StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of predicted healthcare-associated CAUTI among inpatient care locations under surveillance for CAUTI during the data period, based on the national CAUTI baseline.Denominator InclusionsNone listed by measure steward.Denominator ExclusionsThe following are not considered indwelling catheters by NHSN definitions:1.Suprapubic catheters 2.Condom catheters 3.“In and out” catheterizations4. Nephrostomy tubesNote, that if a patient has either a nephrostomy tube or a suprapubic catheter and also has an indwelling urinary catheter, the indwelling urinary catheter will be included in the CAUTI surveillance.Numerator DescriptionTotal number of observed healthcare-associated CAUTI among patients in bedded inpatient care locations (excluding patients in Level II or III neonatal ICUs).Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationCAUTI and catheter days must be collected by trained hospital staff from information available in clinical data sources. The standard population’s CAUTI rates are available from the NHSN Report. The NHSN analysis tool will automatically calculate SIRs. Some of the data used in the measure can be mined from electronic data sources.J1-220: Surgical site infections (SSI) ratesMeasure Description:Surgical site infection rates reported according to the Centers for Disease Control and Prevention’s (CDC) guidance from the 2018 National Healthcare Safety Network (NHSN) Patient Safety Component Manual. DSRIP providers report one aggregate Standardized Infection Ration (SIR) for all procedures. Providers should report on all NHSN operative procedures for which data is available. The SIR is calculated by dividing the number of observed infections by the number of predicted (expected) infections. The number of predicted infections is calculated using SSI probabilities estimated from multivariate logistic regression models constructed from NHSN data during a baseline time period, which represents a standard population’s SSI experience.Providers will report one combined All SSI SIR Model rate for adult and pediatric patients.J1-220: Surgical site infections (SSI) ratesDY7/DY8 Program IDJ1-220Measure DetailsSteward: CDCNQF #: NASource: SourceNHSN ReportRequired StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionTotal number of predicted SSIsDenominator InclusionsReference NHSN manual and software for full bined Patient Population:-Procedures in adult patients-Procedures in pediatric patientsAn NHSN Operative Procedure is a procedure:-that is included in the ICD-10-PCS or CPT NHSN operative procedure code mapping AND-takes place during an operation where at least one incision (including laparoscopic approach and cranial Burr holes) is made through the skin or mucous membrane, or reoperation via an incision that was left open during a prior operative procedure AND-takes place in an operating room (OR), defined as a patient care area that met the Facilities Guidelines Institute’s (FGI) or American Institute of Architects’ (AIA) criteria for an operating room when it was constructed or renovated11. This may include an operating room, C-section room, interventional radiology room, or a cardiac catheterization lab.All SSI SIR Model Inclusion Criteria:-Includes only inpatient procedures-Includes Superficial, Deep & Organ/Space SSIs-Superficial & Deep Incisional SSIs limited to primary incisional SSIs only-Includes SSIs identified on admission, readmission & via post-discharge surveillanceTable 2. Surveillance Periods for SSI Following Selected NHSN Operative Procedure Categories. Day 1 = the date of the procedure.30-day Surveillance-Code and Operative Procedure:AAA: Abdominal aortic aneurysm repairLAM: LaminectomyAMP: Limb amputationLTP: Liver transplantAPPY: Appendix surgeryNECK: Neck surgeryAVSD: Shunt for dialysisNEPH: Kidney surgeryBILI: Bile duct, liver or pancreatic surgeryOVRY: Ovarian surgeryCEA: Carotid endarterectomyPRST: Prostate surgeryCHOL: Gallbladder surgeryREC: Rectal surgeryCOLO: Colon surgerySB: Small bowel surgeryCSEC: Cesarean sectionSPLE: Spleen surgeryGAST: Gastric surgeryTHOR: Thoracic surgeryHTP: Heart transplantTHYR: Thyroid and/or parathyroid surgeryHYST: Abdominal hysterectomyVHYS: Vaginal hysterectomyKTP: Kidney transplantXLAP: Exploratory Laparotomy90-day Surveillance-Code and Operative Procedure:BRST: Breast surgeryCARD: Cardiac surgeryCBGB: Coronary artery bypass graft with both chest and donor site incisionsCBGC: Coronary artery bypass graft with chest incision onlyCRAN: CraniotomyFUSN: Spinal fusionFX: Open reduction of fractureHER: HerniorrhaphyHPRO: Hip prosthesisKPRO: Knee prosthesisPACE: Pacemaker surgeryPVBY: Peripheral vascular bypass surgeryVSHN: Ventricular shuntNote: Superficial incisional SSIs are only followed for a 30-day period for all procedure types.Secondary incisional SSIs are only followed for a 30-day period regardless of the surveillance period for the primary site.Denominator ExclusionsReference NHSN manual and software for all denominator exclusions.In addition to the inclusion criteria, there is also a list of exclusion criteria that applies to all the SSI SIR models. This list is often referred to as the universal exclusion criteria. The list of exclusion criteria applies to both procedures and the associated SSI events. Often the reason for excluding procedures and SSI events from the SIR calculation is due to potential data quality issues. It is important that facilities review their data for quality assurance and to determine the reason for exclusion from the SIR calculation.Table 2. Universal Procedure/SSI Event Exclusions:General Exclusions-Gender= ‘Other’-Outpatient procedures and resulting SSIs-Present at time of surgery (PATOS) is ‘Yes’-SSIs that are reported as superficial incisional secondary (SIS) or deep incisional secondary (DIS)Exclusions due to potential data quality issues or outliers:-Age at the time of procedure is greater than 109 years-Closure technique is missing-ASA score is missing-Gender is missing-Adult patients ≥ 18 years: if BMI is less than 12 or greater than 60*Exclusions: Otherwise eligible procedures that are assigned an ASA score of 6 are not eligible for NHSN SSI surveillance.Note: Incisional closure method is NOT a part of the NHSN operative procedure definition; all otherwise eligible procedures are included, regardless of closure type. Therefore both primarily closed procedures and those that are not closed primarily should be entered into the denominator data for procedures in the facility’s monthly reporting plan. Any SSIs attributable to either primarily closed or non-primarily closed procedures should be reported.-Pediatric patients < 18 years: if BMI less than 10.49 or greater than 65.79**-Procedure duration less than 5 minutes-Procedure duration is greater than IQR5 (please see Table 4 in the SSI Section for more information)Note: Do NOT report procedures with an ASA physical status of 6 (a declared brain-dead patient whose organs are being removed for donor purposes) to NHSN.Numerator DescriptionTotal number of observed SSIsNumerator Inclusions (Performance Met)Reference NHSN manual and software for all numerator inclusions.All patients having any of the procedures included in the selected NHSN operative procedure category(s) are monitored for SSI.Superficial incisional SSIMust meet the following criteria:Date of event for infection occurs within 30 days after any NHSN operative procedure (where day 1 = the procedure date)ANDinvolves only skin and subcutaneous tissue of the incisionANDpatient has at least one of the following:a. purulent drainage from the superficial incision.b. organisms identified from an aseptically-obtained specimen from the superficial incision or subcutaneous tissue by a culture ornon-culture based microbiologic testing method which isperformed for purposes of clinical diagnosis or treatment (forexample, not Active Surveillance Culture/Testing (ASC/AST).c. superficial incision that is deliberately opened by a surgeon,attending physician** or other designee and culture or non-culturebased testing is not performed.ANDpatient has at least one of the following signs or symptoms: pain or tenderness; localized swelling; erythema; or heat.d. diagnosis of a superficial incisional SSI by the surgeon orattending physician** or other designee.** The term attending physician for the purposes of application of the NHSN SSI criteria may be interpreted to mean the surgeon(s), infectious disease, other physician on the case, emergency physician or physician’s designee (nurse practitioner or physician’s assistant).Deep incisional SSIMust meet the following criteria:The date of event for infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the list in Table 2ANDinvolves deep soft tissues of the incision (for example, fascial and muscle layers)ANDpatient has at least one of the following:a. purulent drainage from the deep incision.b. a deep incision that spontaneously dehisces, or is deliberatelyopened or aspirated by a surgeon, attending physician** or otherdesigneeANDorganism is identified by a culture or non-culture based microbiologic testing method which is performed for purposes of clinical diagnosis or treatment (for example, not Active Surveillance Culture/Testing (ASC/AST) or culture or non-culture based microbiologic testing method is not performedANDpatient has at least one of the following signs or symptoms: fever (>38°C); localized pain or tenderness. A culture or non-culture based test that has a negative finding does not meet this criterion.c. an abscess or other evidence of infection involving the deepincision that is detected on gross anatomical or histopathologicexam, or imaging test.** The term attending physician for the purposes of application of the NHSN SSI criteria may be interpreted to mean the surgeon(s), infectious disease, other physician on the case, emergency physician or physician’s designee (nurse practitioner or physician’s assistant).Organ/Space SSIMust meet the following criteria:Date of event for infection occurs within 30 or 90 days after the NHSN operative procedure (where day 1 = the procedure date) according to the list in Table 2ANDinfection involves any part of the body deeper than the fascial/muscle layers, that is opened or manipulated during the operative procedureANDpatient has at least one of the following:a. purulent drainage from a drain that is placed into the organ/space(for example, closed suction drainage system, open drain, T-tubedrain, CT guided drainage)b. organisms are identified from fluid or tissue in the organ/space bya culture or non-culture based microbiologic testing method whichis performed for purposes of clinical diagnosis or treatment (forexample, not Active Surveillance Culture/Testing (ASC/AST).c. an abscess or other evidence of infection involving theorgan/space that is detected on gross anatomical or histopathologicexam, or imaging test evidence suggestive of infection.ANDmeets at least one criterion for a specific organ/space infection site listed in Table 3. These criteria are found in the Surveillance Definitions for Specific Types of Infections chapter.Numerator Exclusions (Performance Not Met)Reference NHSN manual and software for full numerator exclusions.DSRIP Specific ModificationsNoneAdditional InformationNoneJ1-221: Patient Fall RateMeasure Description:All documented falls, with or without injury, experienced by patients on eligible unit types in a calendar quarter. Reported as Total Falls per 1,000 Patient Days.(Total number of falls / Patient days) X 1000J1-221: Patient Fall RateDY7/DY8 Program IDJ1-221Measure DetailsSteward: American Nurses AssociationNQF #: 0141Source: SourceE.H.R.Required StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure 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 DetailsMeasure is NOT eligible for a shortened baseline measurement period.Measure is not eligible for a baseline of 0.Denominator DescriptionDenominator Statement: Patient days by hospital unit during the calendar month times 1000.Denominator InclusionsDenominator Inclusions: ?Inpatients, short stay patients, observation patients, and same day surgery patients who receive care on eligible inpatient units for all or part of a day on the following unit types:?Adult critical care, step-down, medical, surgical, medical-surgical combined, critical access, and adult rehabilitation units.?Patients of any age on an eligible reporting unit are included in the patient day count.Denominator ExclusionsExcluded Populations: Other unit types (e.g., pediatric, psychiatric, obstetrical, etc.)Numerator DescriptionTotal number of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the calendar month X 1000. Target population is adult acute care inpatient and adult rehabilitation patients. Eligible unit types include adult critical care, adult step-down, adult medical, adult surgical, adult medical-surgical combined, critical access, adult rehabilitation in-patient.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, the numerator should be reported as the number of falls x1000.Additional InformationNoneJ1-506: PSI 13 Post Operative Sepsis RateMeasure Description:Postoperative sepsis cases (secondary diagnosis) per 1,000 elective surgical discharges for patientsages 18 years and older. Excludes cases with a principal diagnosis of sepsis, cases with a secondarydiagnosis of sepsis present on admission, cases with a principal diagnosis of infection, cases with asecondary diagnosis of infection present on admission (only if they also have a secondary diagnosisof sepsis), obstetric discharges, and cases with missing values as listed in denominator section.J1-506: PSI 13 Post Operative Sepsis RateDY7/DY8 Program IDJ1-506Measure DetailsSteward: AHRQNQF #: NASource: AHRQ: SourceClaimsRequired StatusRequiredMeasure ClassificationType: Hospital SafetyMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NADirectionality: 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 DescriptionElective surgical discharges (Appendix E ) for patients ages 18 years and older, with any-listed ICD-10-PCS procedure codes for an operating room procedure (Appendix A ). Elective surgical dischargesare defined by specific MS-DRG codes with admission type recorded as elective (SID ATYPE=3).Denominator InclusionsSee measure source for Appenix A and E valuesDenominator ExclusionsExclude cases:? with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) forsepsis (SEPTI2D * ), among patients otherwise qualifying for numerator? with a principal ICD-10-CM diagnosis code (or secondary diagnosis present on admission) forinfection (Appendix F ), among patients otherwise qualifying for numerator? MDC 14 (pregnancy, childbirth, and puerperium)? with missing gender (SEX=missing), age (AGE=missing), quarter (DQTR=missing), year(YEAR=missing), or principal diagnosis (DX1=missing)Numerator DescriptionDischarges, among cases meeting the inclusion and exclusion rules for the denominator, with anysecondary ICD-10-CM diagnosis codes for sepsis (SEPTI2D * ) x1000.Numerator Inclusions (Performance Met)Sepsis diagnosis codes : (SEPTI2D)A021 Salmonella sepsis A227 Anthrax sepsis A267 Erysipelothrix sepsis A327 Listerial sepsis A400 Sepsis due to streptococcus, group A A401 Sepsis due to streptococcus, group B A403 Sepsis due to Streptococcus pneumoniae A408 Other streptococcal sepsis A409 Streptococcal sepsis, unspecified A4101 Sepsis due to Methicillin susceptible Staphylococcus aureusA4102 Sepsis due to Methicillin resistant Staphylococcus aureusA411 Sepsis due to other specified staphylococcusA412 Sepsis due to unspecified staphylococcus A413 Sepsis due to Hemophilus influenzae A414 Sepsis due to anaerobesA4150 Gram-negative sepsis, unspecifiedA4151 Sepsis due to Escherichia coli [E. coli]A4152 Sepsis due to PseudomonasA4153 Sepsis due to SerratiaA4159 Other Gram-negative sepsisA4181 Sepsis due to EnterococcusA4189 Other specified sepsisA419 Sepsis, unspecified organismA427 Actinomycotic sepsisA5486 Gonococcal sepsisB377 Candidal sepsisR6520 Severe sepsis without septic shockR6521 Severe sepsis with septic shockT8112XA Postprocedural septic shock, initial encounterNumerator Exclusions (Performance Not Met)None listed by measure stewardDSRIP Specific ModificationsFor DSRIP reporting purposes, the numerator should be reported as the number of events x1000.Additional InformationSee measure source for included and excluded valuesBundle K1 Rural Preventive CareMeasure Bundle ObjectivesImprove provision of preventive care in rural and critical access hospitals to improve patient health.Target PopulationDSRIP attributed individualsRelated System ComponentsPrimary care, outpatient specialty careNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesYesMeasures Hospital BasedServicesNoK1-103: 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.K1-103: Controlling High Blood PressureDY7/DY8 Program IDK1-103Measure DetailsSteward: NCQANQF #: 0018Source: CMS MIPS #236 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptional with additional points if selectedMeasure 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"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: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)"K1-105: 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 userK1-105: Preventive Care & Screening: Tobacco Use: Screening & Cessation InterventionDY7/DY8 Program IDK1-105Measure DetailsSteward: NCQANQF #: 0028Source: CMS MIPS #226 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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.: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" Numerator 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.:NoneDSRIP 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)"K1-112: Comprehensive Diabetes Care: Foot ExamMeasure Description:The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year.K1-112: Comprehensive Diabetes Care: Foot ExamDY7/DY8 Program IDK1-112Measure DetailsSteward: NCQANQF #: 0056Source: CMS MIPS #163 (Claims/Registry) eMeasure: SourceE.H.R.Required StatusOptional with additional points if selectedMeasure 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 DescriptionPatients 18-75 years of age with diabetes with a visit during the measurement period Exclusions: Patients who have had either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period.Exclude patients who were in hospice care during the measurement year.Denominator InclusionsAND: "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"Providers may 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 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: Bilateral amputation of leg below or above knee" starts before or concurrent with end of "Measurement Period" OR: AND: Union of: "Diagnosis: Right Unilateral Amputation Above or Below Knee" "Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality (anatomical location site: Right)" starts before or concurrent with end of "Measurement Period" AND: Union of: "Diagnosis: Left Unilateral Amputation Above or Below Knee" "Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality (anatomical location site: Left)" starts before or concurrent with end of "Measurement Period"Numerator DescriptionPatients who received a foot exam (visual inspection and sensory exam with monofilament and pulse exam) during the measurement year.Numerator Inclusions (Performance Met)AND: "Physical Exam, Performed: Visual Exam of Foot" during "Measurement Period" AND: "Physical Exam, Performed: Sensory Exam of Foot" during "Measurement Period" AND: "Physical Exam, Performed: Pulse Exam of Foot" during "Measurement Period"Numerator Exclusions (Performance Not Met)NoneDSRIP Specific ModificationsNoneAdditional InformationGuidance:Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of this measure; patients with a diagnosis of secondary diabetes due to another condition should not be included. Data Criteria (QDM Data Elements):? "Diagnosis: Bilateral amputation of leg below or above knee" using "Bilateral amputation of leg below or above knee Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1056)"? "Diagnosis: Diabetes" using "Diabetes Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1001)"? "Diagnosis: Left Unilateral Amputation Above or Below Knee" using "Left Unilateral Amputation Above or Below Knee Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1058)"? "Diagnosis: Right Unilateral Amputation Above or Below Knee" using "Right Unilateral Amputation Above or Below Knee Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1057)"? "Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality" using "Unilateral Amputation Below or Above Knee, Unspecified Laterality Grouping Value Set (2.16.840.1.113883.3.464.1003.113.12.1059)"? "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)"? "Physical Exam, Performed: Pulse Exam of Foot" using "Pulse Exam of Foot Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1015)"? "Physical Exam, Performed: Sensory Exam of Foot" using "Sensory Exam of Foot Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1014)"? "Physical Exam, Performed: Visual Exam of Foot" using "Visual Exam of Foot Grouping Value Set (2.16.840.1.113883.3.464.1003.103.12.1013)"? 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)"K1-115: 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.K1-115: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)DY7/DY8 Program IDK1-115Measure DetailsSteward: NCQANQF #: 0059Source: CMS MIPS #1 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptional with additional points if selectedMeasure 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 periodDenominator 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"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: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 Instructions:INVERSE MEASURE - A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control. Patient is numerator compliant if most recent HbA1c level >9% or is missing a result or if an HbA1c test was not done during the measurement year. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance.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 InformationE.H.R.:Data 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)"K1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD)Measure Description:Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documentedK1-146: Screening for Clinical Depression and Follow-Up Plan (CDF-AD)DY7/DY8 Program IDK1-146Measure DetailsSteward: CMSNQF #: 0418Source: CMS MIPS #134 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptional with additional points if selectedMeasure 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 years and olderDenominator InclusionsCLAIMS/REGISTRY: Patients aged ≥ 12 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92625, 96116, 96118, 96150, 96151, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0101, G0402, G0438, G0439, G0444 E.H.R.: AND: Age>= 12 year(s) at: "Measurement Period" AND: "Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period"Denominator ExclusionsCLAIMS/REGISTRY: Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder, therefore screening or follow-up not required: G9717ORScreening for depression not completed, documented reason (G8433) E.H.R.: OR: "Diagnosis: Depression diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) OR: "Diagnosis: Bipolar Diagnosis" satisfies all: starts before start of ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) overlaps ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" )Numerator DescriptionPatients screened for depression on the date of the encounter using an age appropriate standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screenNumerator Instructions: The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. The depression screening must be reviewed and addressed in the office of the provider filing the code on the date of the encounter. Definitions:Screening – Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms. Standardized Depression Screening Tool – A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to:? Adolescent Screening Tools (12-17 years):Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire (MFQ), Center for Epidemiologic Studies Depression Scale (CES-D), Patient Health Questionnaire (PHQ-9), Pediatric Symptom Checklist (PSC-17), and PRIME MD-PHQ2 ? Adult Screening Tools (18 years and older)Patient Health Questionnaire (PHQ-9), Beck Depression Inventory (BDI or BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale (DEPS), Duke Anxiety- Depression Scale (DADS), Geriatric Depression Scale (GDS), Cornell Scale Screening, and PRIME MD-PHQ2 Follow-Up Plan – Documented follow-up for a positive depression screening must include one or more of the following:? Additional evaluation for depression? Suicide Risk Assessment? Referral to a practitioner who is qualified to diagnose and treat depression? Pharmacological interventions? Other interventions or follow-up for the diagnosis or treatment of depressionNot Eligible for Depression Screening or Follow-Up Plan –? Patient has an active diagnosis of Depression? Patient has a diagnosed Bipolar DisorderPatients with a Documented Reason for not Screening for Depression –One or more of the following conditions are documented:? Patient refuses to participate? Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status? Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of deliriumNumerator Inclusions (Performance Met)CLAIMS/REGISTRY: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)ORScreening for depression is documented as negative, a follow-up plan is not required (G8510) E.H.R.: AND: OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Negative Depression Screening)" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adolescent Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adolescent" "Intervention, Order: Referral for Depression Adolescent" "Medication, Order: Depression medications - adolescent" "Intervention, Performed: Follow-up for depression - adolescent" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adolescent Depression Screening" AND: Age< 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Negative Depression Screening)" AND: Age>= 18 year(s) at: "Measurement Period" OR: AND: Most Recent: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result)" during ("Encounter, Performed: Depression Screening Encounter Codes" during "Measurement Period" ) AND: "Occurrence A of Risk Category Assessment: Adult Depression Screening (result: Positive Depression Screening)" AND: Union of: "Intervention, Performed: Additional evaluation for depression - adult" "Intervention, Order: Referral for Depression Adult" "Medication, Order: Depression medications - adult" "Intervention, Performed: Follow-up for depression - adult" "Procedure, Performed: Suicide Risk Assessment" <= 1 day(s) starts after or concurrent with start of "Occurrence A of Risk Category Assessment: Adult Depression Screening" AND: Age>= 18 year(s) at: "Measurement Period"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Depression screening not documented, reason not given (G8432)ORScreening for depression documented as positive, follow-up plan not documented, reason not given (G8511) E.H.R.:NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Diagnosis: Bipolar Diagnosis" using "Bipolar Diagnosis Grouping Value Set (2.16.840.1.113883.3.600.450)"? "Diagnosis: Depression diagnosis" using "Depression diagnosis Grouping Value Set (2.16.840.1.113883.3.600.145)"? "Encounter, Performed: Depression Screening Encounter Codes" using "Depression Screening Encounter Codes Grouping Value Set (2.16.840.1.113883.3.600.1916)"? "Intervention, Order: Referral for Depression Adolescent" using "Referral for Depression Adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.537)"? "Intervention, Order: Referral for Depression Adult" using "Referral for Depression Adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.538)"? "Intervention, Performed: Additional evaluation for depression - adolescent" using "Additional evaluation for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.1542)"? "Intervention, Performed: Additional evaluation for depression - adult" using "Additional evaluation for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.1545)"? "Intervention, Performed: Follow-up for depression - adolescent" using "Follow-up for depression - adolescent SNOMEDCT Value Set (2.16.840.1.113883.3.600.467)"? "Intervention, Performed: Follow-up for depression - adult" using "Follow-up for depression - adult SNOMEDCT Value Set (2.16.840.1.113883.3.600.468)"? "Medication, Order: Depression medications - adolescent" using "Depression medications - adolescent RXNORM Value Set (2.16.840.1.113883.3.600.469)"? "Medication, Order: Depression medications - adult" using "Depression medications - adult RXNORM Value Set (2.16.840.1.113883.3.600.470)"? "Procedure, Performed: Suicide Risk Assessment" using "Suicide Risk Assessment SNOMEDCT Value Set (2.16.840.1.113883.3.600.559)"? "Risk Category Assessment: Adolescent Depression Screening" using "Adolescent Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2452)"? "Risk Category Assessment: Adult Depression Screening" using "Adult Depression Screening LOINC Value Set (2.16.840.1.113883.3.600.2449)"? "Risk Category Assessment 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)"? "Risk Category Assessment not done: Patient Reason refused" using "Patient Reason refused SNOMEDCT Value Set (2.16.840.1.113883.3.600.791)"? Attribute: "Result: Negative Depression Screening" using "Negative Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2451)"? Attribute: "Result: Positive Depression Screening" using "Positive Depression Screening SNOMEDCT Value Set (2.16.840.1.113883.3.600.2450)"K1-268: Pneumonia vaccination status for older adultsMeasure Description:Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.K1-268: Pneumonia vaccination status for older adultsDY7/DY8 Program IDK1-268Measure DetailsSteward: CMSNQF #: 0043Source: CMS MIPS #111 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 periodDENOMINATOR 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, G043999387, 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"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 ModificationsNoneAdditional 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)"K1-269: 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 immunizationK1-269: Preventive Care and Screening: Influenza ImmunizationDY7/DY8 Program IDK1-269Measure DetailsSteward: AMA / PCPINQF #: 0041 / 3070 eMeasureSource: CMS MIPS #110 (Claims/Registry) eMeasure: SourceE.H.R.Required StatusOptional with additional points if selectedMeasure 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)"K1-285: Advance Care PlanMeasure Description:Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.K1-285: Advance Care PlanDY7/DY8 Program IDK1-285Measure DetailsSteward: NCQANQF #: 0326Source: CMS MIPS #47 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure 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 65 years and older DENOMINATOR NOTE: Eligible clinicians indicating the Place of Service as the emergency department will not be included in this measure.Denominator InclusionsPatients aged ≥ 65 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439Denominator ExclusionsHospice services received by patient any time during the measurement period: G9692Numerator DescriptionPatients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Numerator Instructions: If patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, report 1124F. NUMERATOR NOTE: The CPT Category II codes used for this measure indicate: Advance Care Planning was discussed and documented. The act of using the Category II codes on a claim indicates the provider confirmed that the Advance Care Plan was in the medical record (that is, at the point in time the code was assigned, the Advance Care Plan in the medical record was valid) or that advance care planning was discussed. The codes are required annually to ensure that the provider either confirms annually that the plan in the medical record is still appropriate or starts a new discussion. The provider does not need to review the Advance Care Plan annually with the patient to meet the numerator criteria, documentation of a previously developed advanced care plan that is still valid in the medical record meets numerator criteria. Definition:Documentation that Patient did not Wish or was not able to Name a Surrogate Decision Maker or Provide an Advance Care Plan – May also include, as appropriate, the following:? That the patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patientNumerator Inclusions (Performance Met)Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record (1123F)OR Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (1124F)Numerator Exclusions (Performance Not Met)Advance care planning not documented, reason not otherwise specified (1123F with 8P)DSRIP Specific ModificationsNoneAdditional InformationNoneK1-300: Behavioral Health Risk Assessment (for Pregnant Women)Measure Description:Percentage of women, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care who received a behavioral health screening risk assessment that includes the following screenings at the first prenatal visit: depression screening, alcohol use screening, tobacco use screening, drug use screening (illicit and prescription, over the counter), and intimate partner violence screening.K1-300: Behavioral Health Risk Assessment (for Pregnant Women)DY7/DY8 Program IDK1-300Measure DetailsSteward: AMA-PCPINQF #: NASource: Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set) 2017 SourceE.H.R.Required StatusOptional with additional points if selectedMeasure 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, regardless of age, who gave birth during a 12-month period seen at least once for prenatal care.Denominator InclusionsLOGIC: ENCOUNTER Performed, Prenatal Visit: "2.16.840.1.113883.3.526.3.1264"AND PROCEDURE Performed Vaginal Delivery: "2.16.840.1.113883.3.526.3.1341" Attribute: stop datetime Date of Delivery OR PROCEDURE Performed: Cesarean Section Delivery: "2.16.840.1.113883.3.526.3.1342" Attribute: stope datetime Dat of DeliveryDenominator ExclusionsNo Valid Denominator Exclusions or Exceptions for this Measure.Numerator DescriptionPatients who received all behavioral health screening risk assessments at the first prenatal visit.Numerator Inclusions (Performance Met)Patients who received the following behavioral health screening risk assessments at the first prenatal visit.Depression screening:? Patients who were screened for depression at the first visit. 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)].Alcohol use screening:? Patients who were screened for any alcohol use at the first visit Tobacco use screening:? Patients who were screened for tobacco use at the first visit Drug use (illicit and prescription, over the counter) screening:? Patients who were screened for any drug use at the first visitIntimate partner violence screening:? Patients who were screened for intimate partner violence/abuse at the first visit. 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. Intimate partner violence screening may include a self-reported validated depression screening tool (e.g., Hurt, Insult, Threaten, and Scream [HITS], Woman Abuse Screening Tool [WAST], Partner Violence Screen [PVS], Abuse Assessment Screen [AAS]).To satisfactorily meet the numerator, ALL screening components must be performed. LOGIC:All Patients Identified within the DenominatorAND RISK CATEGORY/ASSESSMENT Result; Depression Screening Tools Realted to Maternity Care: "2.16.840.1.113883.3.526.3.1359" Attirbute: Result Value Present OR INTERVENTION Result; Depression Screening-Procedure: "2.16.840.1.113883.3.526.3.1360" Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result; Alcohol Use Screening: "2.16.840.1.113883.3.526.3.1361"Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result; Tobacco Use Screening: "2.16.840.1.113883.3.526.3.1362"Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result; Illicit, Prescription and Over the Counter Drug Use Screening: "2.16.840.1.113883.3.526.3.1363"Attribute: Result Value PresentANDRISK CATEGORY/ASSESSMENT Result, Intimate Partner Violence Screening-Tool; "2.16.840.1.113883.3.526.3.1364"Attribute: Result Value PresentNumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional Information? To satisfactorily meet the numerator, all screening components must be performed.? The specifications for this measure do not include upper or lower age restrictions.? If an eligible woman has more than one birth during the measurement year, states should count each delivery separately in the Denominator (D). To be counted toward the numerator, each delivery must have a BHRA conducted at the first prenatal visit within the specified time frame for each delivery. Additional guidance can be found in the Medicaid and Chip Child Core Set Technical Specifications and Resource Manual for Federal Fiscal Year 2017 Allowable Exceptions: - Measure is specified for prenatal visits. For DSRIP reporting purposes, providers MAY include settings in addition to OB that may provide care to pregnant women. - Measure is specified so that denominator inclusion is determined by a delivery during the measurement period and a prenatal visit prior to delivery. For DSRIP repororting purposes, providers MAY deterimne denominator inclusion by a prenatal visit conducted during the measurement period, rather than delivery date within the measurement period. Providers should keep record of above exceptions and note them in the qualitative fields when reporting baseline or performance rates. Providers must apply exceptions consistantly across all baseline and performance years.Bundle K2 Rural Emergency CareMeasure Bundle ObjectivesImprove quality of emergency care in rural and critical access hospital to improve patient health.Target PopulationIndividuals receiving emergent care during the measurement year as defined by the measure denominatorRelated System ComponentsRural HospitalNOTE: System components are included for planning purposes only and are not intended to further narrow the measure bundle target population or measure denominator specificationsMeasures Outpatient ServicesNoMeasures Hospital BasedServicesYesK2-285: Advance Care PlanMeasure Description:Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.K2-285: Advance Care PlanDY7/DY8 Program IDK2-285Measure DetailsSteward: NCQANQF #: 0326Source: CMS MIPS #47 (Claims/Registry)Data SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusOptional with additional points if selectedMeasure 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 65 years and older DENOMINATOR NOTE: Eligible clinicians indicating the Place of Service as the emergency department will not be included in this measure.Denominator InclusionsPatients aged ≥ 65 years on date of encounterANDPatient encounter during the performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235, 99236, 99291, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439Denominator ExclusionsHospice services received by patient any time during the measurement period: G9692Numerator DescriptionPatients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan Numerator Instructions: If patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, report 1124F. NUMERATOR NOTE: The CPT Category II codes used for this measure indicate: Advance Care Planning was discussed and documented. The act of using the Category II codes on a claim indicates the provider confirmed that the Advance Care Plan was in the medical record (that is, at the point in time the code was assigned, the Advance Care Plan in the medical record was valid) or that advance care planning was discussed. The codes are required annually to ensure that the provider either confirms annually that the plan in the medical record is still appropriate or starts a new discussion. The provider does not need to review the Advance Care Plan annually with the patient to meet the numerator criteria, documentation of a previously developed advanced care plan that is still valid in the medical record meets numerator criteria. Definition:Documentation that Patient did not Wish or was not able to Name a Surrogate Decision Maker or Provide an Advance Care Plan – May also include, as appropriate, the following:? That the patient’s cultural and/or spiritual beliefs preclude a discussion of advance care planning, as it would be viewed as harmful to the patient's beliefs and thus harmful to the physician-patientNumerator Inclusions (Performance Met)Advance Care Planning discussed and documented; advance care plan or surrogate decision maker documented in the medical record (1123F)OR Advance Care Planning discussed and documented in the medical record; patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan (1124F)Numerator Exclusions (Performance Not Met)Advance care planning not documented, reason not otherwise specified (1123F with 8P)DSRIP Specific ModificationsNoneAdditional InformationNoneK2-287: Documentation of Current Medications in the Medical RecordMeasure Description:Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administrationK2-287: Documentation of Current Medications in the Medical RecordDY7/DY8 Program IDK2-287Measure DetailsSteward: CMSNQF #: 0419Source: CMS MIPS #130 (Claims/Registry) eMeasure: SourceProvider should utilize either claims or E.H.R. version of specificationsRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll visits for patients aged 18 years and olderDenominator InclusionsCLAIMS/REGISTRY:Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter AND Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 90839, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92585, 92588, 92626, 96116, 96150, 96151, 96152, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97532, 97802, 97803, 97804, 98960, 98961, 98962, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99495, 99496, G0101, G0108, G0270, G0402, G0438, G0439 E.H.R.: AND: Age>= 18 year(s) at: "Measurement Period" AND: "Occurrence A of Encounter, Performed: Medications Encounter Code Set" during "Measurement Period"Denominator ExclusionsCLAIMS, REGISTRY:Eligible clinician attests to documenting in the medical record the patient is not eligible for a current list of medications being obtained, updated, or reviewed by the eligible clinician (G8430) E.H.R.:NoneNumerator DescriptionEligible clinician attests to documenting, updating or reviewing a patient’s current medications using all resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration Definitions:Current Medications – Medications the patient is presently taking including all prescriptions, over-the- counters, herbals and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.Route – Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical) Not Eligible (Denominator Exception) – A patient is not eligible if the following reason is documented:?Patient is in an urgent or emergent medical situation where time is of the essence and to delaytreatment would jeopardize the patient’s health status NUMERATOR NOTE: The eligible clinician must document in the medical record they obtained, updated, or reviewed a medication list on the date of the encounter. Eligible clinicians reporting this measure may document medication information received from the patient, authorized representative(s), caregiver(s) or other available healthcare resources. G8427 should be reported if the eligible clinician documented that the patient is not currently taking any medicationsNumerator Inclusions (Performance Met)CLAIMS, REGISTRY:Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient’s current medications (G8427) E.H.R.: AND: "Procedure, Performed: Current Medications Documented SNMD" during "Occurrence A of Encounter, Performed: Medications Encounter Code Set"Numerator Exclusions (Performance Not Met)CLAIMS/REGISTRY:Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given (G8428) NoneDSRIP Specific ModificationsNoneAdditional InformationData Criteria (QDM Data Elements):? "Encounter, Performed: Medications Encounter Code Set" using "Medications Encounter Code Set Grouping Value Set (2.16.840.1.113883.3.600.1.1834)"? "Procedure, Performed: Current Medications Documented SNMD" using "Current Medications Documented SNMD SNOMEDCT Value Set (2.16.840.1.113883.3.600.1.462)"? "Procedure, 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)"K2-355: Admit Decision Time to ED Departure Time for Admitted PatientsMeasure Description:Median time (in minutes) from admit decision time to time of discharge from the emergency department for emergency department patients admitted to inpatient status.K2-355: Admit Decision Time to ED Departure Time for Admitted PatientsDY7/DY8 Program IDK2-355Measure DetailsSteward: CMSNQF #: 0497Source: SourceE.H.R.Required StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: NegativeUnit of Measurement for Payer TypeUnit: EncountersMeasure will be reported for all-payer, and MLIU 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 DescriptionFor DSRIP reporting purposes, the denominator is 1 so that the resulting rate is the median time in minutes from admit decision time to time of discharge from the emergency department for emergency department patients admitted to inpatient status.Denominator InclusionsNADenominator ExclusionsNANumerator DescriptionMedian time in minutes. Report total rate only.Numerator Inclusions (Performance Met)NANumerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsFor DSRIP reporting purposes, report only the total score of specified stratifications. For DSRIP reporting purposes, providers will report a single median rate for all MLIU cases (instead of a Medicaid and an LIU rate), and a single median rate for all all-payer cases unless a reoprting milestone exception is approved. Additional InformationInitial patient population: Inpatient Encounters ending during the measurement period with Length of Stay (Discharge Date minus Admission Date) less than or equal to 120 days.Measure Population: Inpatient Encounters where the decision to admit was made during the preceding emergency department visit. Guidance: - This measure specification defines how to determine the duration from a Decision to Admit and the departure from an Emergency Department stay. Reporting requires the median of all admit decision to ED departure durations defined as [Encounter: encounter ED] facility location departure date and time minus [Encounter: encounter ED] ED admit decision date and time.- Decision to Admit: First documentation of the decision to admit the patient from the ED. Specification: as admission processes vary at different hospitals, this can use the first documented time of any of the following: 1) admission order (this may be an operational order rather than the hospital admission to inpatient status order), 2) disposition order (must explicitly state to admit), 3) documented bed request, or 4) documented acceptance from admitting physician. This is not the bed assignment time or report called time.- Calculate the ED time in minutes for each patient in the measure population; report the median time for all calculations performed. The specification provides elements from the clinical electronic record required to calculate for each ED encounter, i.e., the length of time the patient was in the Emergency Department from the time of decision to admit, also stated as: the Datetime difference for the Emergency Department facility location departure date/time minus the Decision to Admit date/time. The calculation requires the median across all ED encounter durations. LOGIC Initial Population = AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before or concurrent with start of Occurrence A of $EncounterInpatient AND: "Occurrence A of Encounter, Order: Decision to Admit to Hospital Inpatient" satisfies all: - starts during "Occurrence A of Encounter, Performed: Emergency Department Visit" - starts before start of "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)"Measure Population = AND: Initial PopulationMeasure Population Exclusions = OR: "Transfer From: Hospital Settings" <= 6 hour(s) ends before or concurrent with start of "Occurrence A of Encounter, Performed: Emergency Department Visit"Measure Observation = Median: Datetimediff: - "Occurrence A of Encounter, Performed: Emergency Department Visit (facility location departure datetime)" - "Occurrence A of Encounter, Order: Decision to Admit to Hospital Inpatient (start datetime)"Stratifications = Stratification 1 = AND NOT: Intersection of: - Occurrence A of $EncounterInpatient - "Encounter, Performed: Encounter Inpatient (principal diagnosis: Psychiatric/Mental Health Patient)" Stratification 2 = AND: Intersection of: - Occurrence A of $EncounterInpatient - "Encounter, Performed: Encounter Inpatient (principal diagnosis: Psychiatric/Mental Health Patient)" Data Criteria (QDM Variables) $EncounterInpatient = "Encounter, Performed: Encounter Inpatient" satisfies all: - (length of stay <= 120 day(s)) - ends during "Measurement Period" Data Criteria (QDM Data Elements):- "Encounter, Order: Decision to Admit to Hospital Inpatient" using "Decision to Admit to Hospital Inpatient Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.295)"- "Encounter, Performed: Emergency Department Visit" using "Emergency Department Visit SNOMEDCT Value Set (2.16.840.1.113883.3.117.1.7.1.292)"- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient SNOMEDCT Value Set (2.16.840.1.113883.3.666.5.307)"- "Transfer From: Hospital Settings" using "Hospital Settings SNOMEDCT Value Set (2.16.840.1.113762.1.4.1111.126)"- Attribute: "Principal diagnosis: Psychiatric/Mental Health Patient" using "Psychiatric/Mental Health Patient Grouping Value Set (2.16.840.1.113883.3.117.1.7.1.299)" Supplemental Data Elements:- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity CDCREC Value Set (2.16.840.1.114222.4.11.837)"- "Patient Characteristic Payer: Payer" using "Payer SOP Value Set (2.16.840.1.114222.4.11.3591)"- "Patient Characteristic Race: Race" using "Race CDCREC Value Set (2.16.840.1.114222.4.11.836)"- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex AdministrativeGender Value Set (2.16.840.1.113762.1.4.1)"K2-359: Emergency Transfer Communication MeasureMeasure Description:Percentage of patients transferred to another healthcare facility whose medical record documentation indicated that REQUIRED information was communicated to the receiving facility prior to departure OR WITHIN 60 MINUTES OF TRANSFERK2-359: Emergency Transfer Communication MeasureDY7/DY8 Program IDK2-359Measure DetailsSteward: University of Minnesota Rural Health Research CenterNQF #: 0291Source: SourceAnyRequired StatusRequiredMeasure ClassificationType: ProcessMeasure Parts: 1Achievement CalculationsCategory: P4PGoal Calculation: IOSHPL: NAMPL: NANADirectionality: 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 DescriptionAll transfers from ED to another health care facilityDenominator InclusionsThe population of the EDTC measure set is defined by identifying patients admitted to the emergency department and transfers from the emergency department to these facilities: 3 Hospice – healthcare facility 4a Acute Care Facility- General Inpatient Care 4b Acute Care Facility- Critical Access Hospital 4c Acute Care Facility- Cancer Hospital or Children’s Hospital 4d Acute Care Facility – Department of Defense or Veteran’s Administration 5 Other health care facility (i.e. nursing homes, skilled nursing facilities, rehabilitation centers, swing beds; facilities with 24 hour nursing supervision.) Note: ED patients that have been put in observation status and then are transferred to another hospital or health care facility should be included.(Update discharge codes with CMS changes as appropriate.)Denominator Exclusions1 Home2 Hospice-home6 Expired7 AMA (left against medical advice)8 Not documented/unable to determineNumerator DescriptionNumber of patients transferred to another healthcare facility whose medical record documentation indicated that all of the relevant elements for each of the 7 submeasures were communicated to the receiving hospital within 60 minutes of discharge.Numerator Inclusions (Performance Met)# of patients from thedenominator have a yes or NA for all of the following: ? EDTC-SUB 1 Administrative communication: nurse to nurse communication, physician to physician communication? EDTC-SUB 2 Patient information: name, address, age, gender, contact, insurance? EDTC-SUB 3 Vital signs: pulse,respiration, blood pressure, oxygen saturation, temperature, neuro assessment? EDTC-SUB 4 Medication information: Medications administered in ED, allergies, home medications? EDTC-SUB 5 Physician or practitioner generated information: history and physical and reason for transfer, and/or plan of care? EDTC-SUB 6 Nurse generated information: assessments/interventions/response, sensory status (formerly impairments), catheter, immobilization, respiratory support, oral limitations? EDTC-SUB 7 Procedures and tests: test and procedures done, test and procedure results sent Definition: “sent” refers to medical record documentation that indicates information went with the patient or was communicated via fax or phone or internet/Electronic Health Recordconnection availability within 60 minutes of the patient’s discharge. Data Element Name: Nurse to Nurse CommunicationCollected For: Emergency Department Records: EDTC-SUB 1- Suggested Data Collection Question: Does the medical record documentation indicate that nurse-tonurse communication occurred prior to discharge of the patient from the ED to another healthcare facility?- AllowableValues:- Y (Yes) Select this option if there is documentation of the ED nurse communicating with the nursing staff of the receiving facility.- N (No) Select this option if there is no documentation of the ED nurse communicating with the nursing staff of the receiving facility.Notes for Abstraction:- Documentation must indicate that nurse to nurse communication occurred prior to transfer.- Date and time of contact can be used to verify that communication occurred prior to transfer. If communication is given to a transfer coordinator at the receiving facility, the coordinator must be a nurse to select yes.- House supervisor is assumed to be a nurse- This does not need to be full report. Acceptable communication includes assuring the availability of appropriate bed and staff for the patient.- As small rural hospitals increasingly use staffing models which include paramedics and EMTs in ED roles, note that communication for this data element may occur between these staff (paramedics and EMTs) and nurses at the receiving facility.Suggested Data Sources: Emergency Department record, Transfer Summary document, Nursing note Data Element Name: Physician to Physician CommunicationCollected For: Emergency Department records: EDTC-SUB 1Suggested Data Collection Question: Does the medical record documentation indicate that physician/advanced practice nurse/physician assistant (physician/APN/PA) to physician/APN/PA communication occurred prior to the transfer of the patient from the ED to another healthcare facility?AllowableValues:- Y (Yes) Select this option if there is documentation of the ED physician/APN/PA discussion of the patient’s condition with physician/APN/PA staff at the receiving facility.- N (No) Select this option if there is no documentation of the ED physician/APN/PA discussion of the patient’s condition with physician/APN/PA at the receiving facility.- N/A (Not Applicable) Select this option if the transfer is to a non-acute care healthcare facility.Notes for Abstraction:- Must include the names of the two communicating providers.- Documentation must indicate that ED physician/APN/PA to ED physician/APN/PA communication occurred prior to transfer.- Date and time of contact can be used to verify that communication occurred prior to transfer.Suggested Data Sources: Emergency Department record, Transfer Summary document, EMTALA form Data Element Name: Physician to Physician CommunicationCollected For: Emergency Department records: EDTC-SUB 1Suggested Data Collection Question: Does the medical record documentation indicate that physician/advanced practice nurse/physician assistant (physician/APN/PA) to physician/APN/PA communication occurred prior to the transfer of the patient from the ED to another healthcare facility?AllowableValues:- Y (Yes) Select this option if there is documentation of the ED physician/APN/PA discussion of the patient’s condition with physician/APN/PA staff at the receiving facility.- N (No) Select this option if there is no documentation of the ED physician/APN/PA discussion of the patient’s condition with physician/APN/PA at the receiving facility.- N/A (Not Applicable) Select this option if the transfer is to a non-acute care healthcare facility.Notes for Abstraction:- Must include the names of the two communicating providers.- Documentation must indicate that ED physician/APN/PA to ED physician/APN/PA communication occurred prior to transfer.- Date and time of contact can be used to verify that communication occurred prior to transfer.Suggested Data Sources: Emergency Department record, Transfer Summary document, EMTALA form Data Element Name: Patient NameCollected For: Emergency Department Records: EDTC-SUB 2Suggested Data Collection Question: Does the medical record documentation indicate that the patient’s name was sent to the receiving facility?Allowable Values:- Y (Yes) Select this option if there is documentation that the patient’s name was sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s name was sent to the receiving facility.- NA (Not Applicable) Select this option if this information was not available.Notes for Abstraction:- If the patient is a John/Jane Doe, and/or is altered neurologically select NA- If the patient has a potential brain/head injury select NA.- If the patient refuses to answer the question select NA.Suggested Data Sources: Emergency Department record, Face sheet, Transfer Summary document Data Element Name: Patient AddressSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s address was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s address was sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s address was sent to the receiving facility.- NA (Not Applicable) Select this option if this information was not availableNotes for Abstraction:- If the patient is a John/Jane Doe, and/or is altered neurologically select NA- If the patient has a potential brain/head injury select NA- If the patient refuses to answer the question select NA.Suggested Data Sources: Emergency Department record, Face sheet, Transfer Summary document Data Element Name: Patient AgeSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s age was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s age was sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s age was sent to the receiving facility.- NA (Not Applicable) Select this option if this information was not availableNotes for Abstraction:- If the patient is a John/Jane Doe, and/or is altered neurologically select NA.- If the patient has a potential brain/head injury select NA- If the patient refuses to answer the question select NA.- If the patient’s date of birth was sent select yes.Suggested Data Sources: Emergency Department record, Face sheet, Transfer Summary document Data Element Name: Patient GenderSuggested Data Collection Question: Does the medical record documentation indicate that the patient gender was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that gender was sent to the receiving facility.- N (No) Select this option if there is no documentation that gender was sent to the receiving facility.- NA (Not Applicable) Select this option if this information was not available or unable to be determinedSuggested Data Sources: Emergency Department record, Face sheet, Transfer Summary document Data Element Name: Patient Contact InformationSuggested Data Collection Question: Does the medical record documentation indicate that contact information for a family member/significant other/friend was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that contact information was sent to the receiving facility.- N (No) Select this option if there is no documentation that contact information was sent to the receiving facility.- NA (Not Applicable) Select this option if this information was not availableNotes for Abstraction:- The patient’s contact can be a family member, significant other or friend.- Contact information must include both a name and phone number.- Can have more than one contact but must have at least one.- If the patient is a John/Jane Doe and/or is altered neurologically select NA.- If the patient has a potential brain/head injury select NA.- If the patient refuses to answer the question select NA.Suggested Data Sources: Emergency Department record, Face sheet, Transfer Summary document Data Element Name: Patient Insurance InformationSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s insurance information was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that insurance information was sent to the receiving facility.- N (No) Select this option if there is no documentation that insurance information was sent to the receiving facility.- NA (Not Applicable) Select this option if this information was not availableNotes for Abstraction:- Information must include both the insurance company name and policy number.- If patient does not have insurance and uninsured status is documented, select yes.- If the patient is a John/Jane Doe and/or is altered neurologically select NA.- If the patient has a potential brain/head injury select NA.- If the patient refuses to answer the question select NA.Suggested Data Sources: Emergency Department record, Face sheet, Copy of insurance card, Transfer Summary document Data Element Name: PulseSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s pulse was taken and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s pulse was taken and sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s pulse was taken and or sent to the receiving facility.Suggested Data Sources: Emergency Department record, Nursing Notes, Transfer Summary document Data Element Name: Respiratory RateSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s respiratory rate was taken and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s respiratory rate was taken and sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s respiratory rate was taken and sent to the receiving facility.Suggested Data Sources: Emergency Department record, Nursing Notes Data Element Name: Blood PressureSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s blood pressure was taken and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s blood pressure was taken and sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s blood pressure was taken and sent to the receiving facility.- NA (Not Applicable) Select this option if the patient is less than or equal to 3 years of age. Select this option if a Blood Pressure is unable to be assessed due to patients’ behavior or mental status.Suggested Data Sources: Emergency Department record, Face sheet, Transfer Summary document Data Element Name: Oxygen SaturationSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s oxygen saturation (O2 Sat) was taken and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s oxygen saturation (O2 Sat) was taken and was sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s oxygen saturation (O2 Sat) was taken and sent to the receiving facility.Suggested Data Sources: Emergency Department record, Nursing Notes, Transfer Summary document Data Element Name: TemperatureSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s temperature was taken and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the patient’s was taken and the temperature was sent to the receiving facility.- N (No) Select this option if there is no documentation that the patient’s temperature was taken and sent to the receiving facility.- NA (Not Applicable) Select this option if the temperature is not required. See notes for abstraction.Notes for Abstraction:Temperature is required for patients with physician/APN/PA documentation of suspected infection, hypothermia or heat disorder.Suggested Data Sources: Emergency Department record, Nursing Notes, Transfer Summary document Data Element Name: Neurological AssessmentSuggested Data Collection Question: Does the medical record documentation indicate that a neurological assessment was done on patients at risk for altered consciousness and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that a neuro assessment was done and sent to the receiving facility.- N (No) Select this option if there is no documentation that a neuro assessment for the condition was done and sent to the receiving facility.- NA (Not Applicable) Select this option if a neurologic assessment is not required due to no documentation of altered consciousness, possible brain/head injury, trauma or post seizure, stroke, TIA condition.Notes for Abstraction: Only required for patients with documentation of: Altered consciousness, Possible brain/head injury, Post seizure, Trauma, Stroke, TIASuggested Data Sources: Emergency Department record, Birth or delivery record, Transfer Summary document, Glasgow coma scale, Neuro flow sheets Data Element Name: Medications Administered in EDSuggested Data Collection Question: Does the medical record documentation indicate that the list of medication(s) administered or that no medications were administered in the ED was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that the list of medications administered were sent to the receiving facility.- N (No) Select this option if there is no documentation that the list of medications administered were sent to the receiving facility.Notes for Abstraction:- If no medications were given during the ED visit, documentation must state that there were no medications given to select yes.- Medication information documented anywhere in the ED record is acceptable.Suggested Data Sources: Emergency Department record, Medication Administration Record (MAR) if part of the ED documentation for the current encounter, Transfer Summary document Data Element Name: Allergies/ReactionsSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s allergy history was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation the patient’s allergy information was sent to the receiving facility.N (No) Select this option if there is no documentation the patient’s allergy information was sent to the receiving facility.Notes for Abstraction:- See inclusion guidelines for what should be contained in the allergy information.- If documentation is sent that allergies are unknown, select yes.Suggested Data Sources: Emergency Department record, Transfer SummaryInclusion Guidelines for Abstraction:- Food allergies/reactions- Medication allergies/reactions- Other allergies/reactions Data Element Name: Home MedicationsSuggested Data Collection Question: Does the medical record documentation indicate that the patient’s medication history was sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation medication history was sent to the receiving facility.- N (No) Select this option if there is no documentation medication history was sent to the receiving facility.Notes for Abstraction:- If documentation indicates patient is not on any home medications, select yes.- If documentation is sent that home medications are unknown, select yesSuggested Data Sources: Emergency Department record, Transfer SummaryInclusion Guidelines for Abstraction:- Complimentary medications- Over the counter (OTC) medications Data Element Name: History and PhysicalSuggested Data Collection Question: Does the medical record documentation indicate that a history and physical was done by the physician/advanced practice nurse/physician assistant (physician/APN/PA) and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation a history and physical was done and sent to the receiving facility.- N (No) Select this option if there is no documentation that a history and physical was done and sent to the receiving facility.Notes for Abstraction:- Must minimally include history of the current ED episode, a focused physical exam and relevant chronic conditions. Chronic conditions may be excluded if the patient is neurologically altered.Suggested Data Sources: Emergency Department record, Transfer Summary Data Element Name: Reason for Transfer/Plan of CareSuggested Data Collection Question: Does the medical record documentation indicate that a reason for transfer and/or plan of care was done by the physician/advanced practice nurse/physician assistant (physician/APN/PA) and sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation a reason for transfer or plan of care was done and sent to the receiving facility.- N (No) Select this option if there is no documentation that a reason for transfer or plan of care was done and sent to the receiving facility.Notes for Abstraction:- May include suggestions for care to be received at the receiving facility.Suggested Data Sources: Emergency Department record, Transfer Summary, EMTALA form Data Element Name: Nursing NotesSuggested Data Collection Question: Does the medical record documentation indicate that nursing notes were sent to the receiving facility?AllowableValues:- Y (Yes) Select this option if there is documentation that nursing notes were sent to the receiving facility.- N (No) Select this option if there is no documentation that nursing notes were sent to the receiving facility.Notes for Abstraction:- Examples of nursing notes may include nursing assessment, intervention, response or SOAP notes.Suggested Data Sources: Emergency Department record, Transfer Summary (Cont'd in "additional information")Numerator Exclusions (Performance Not Met)NADSRIP Specific ModificationsNoneAdditional InformationSample Size Requirements- Hospitals that choose to sample have the option of sampling quarterly or sampling monthly. A hospital may choose to use a larger sample size than is required. Hospitals whose initial patient population size is less than the minimum number of cases per quarter for the measure set cannot sample.- Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. Due to exclusions, hospitals selecting sample casesMUST submit AT LEAST the minimum required sample size.- The following sample sizes for each option automatically build in the number of cases needed to obtain the required sample sizes. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in the measure steward's manual. Quarterly Sampling: Hospitals performing quarterly sampling for ED Transfer Communication must ensure that its initial patient population and sample size meet the following conditions:Quarterly Sample Size (Based on Initial Patient Population Size for the EDTC Measure Set) - if Average Quarterly Initial Patient Population Size is greater than or equal to 45, minimum required sample size is 45 - if Average Quarterly Initial Patient Population Size is less than 45, no sampling allowed - 100% of initial patient population is required No sampling; 100% Initial Patient Population required Monthly Sampling: Hospitals performing monthly sampling for EDTC must ensure that its Initial Patient Population and sample size meet the following conditions:Monthly Sample Size (Based on Initial Patient Population Size for the EDTC Measure Set) - if Average Monthly Initial Patient Population is greater than or equal to 15, minimum required sample size is 15 - if Average Monthly Initial Patient Population is less than 15, no sampling allowed - 100% of initial patient population is required Subsection Measure Calculation:- Each of the seven SUB SECTIONS ARE calculated using an all-or-none approach. Data elements are identified for each SUBSECTION. If the data element is not appropriate for the patient, elements are scored as NA (not applicable) and are counted in the measure as a positive, or ‘yes,’ response and the patient will meet that element criteria. The patient will either need to meet the criteria for all of the data elements (or have an NA) to pass the SUBSECTION. The subsections are used to identify areas with opportunity for improvement.- The reporting measure is a sum of the subsection scores divided by the number of patients. The facility score is the average of the patients scores (range of 0-7) for each facility. This single score will provide an overview of the facility’s communication performance for patients that are transferred from their Emergency Department to another healthcare facility.(HHSC NOTE: Subsection Measure Calculation included for provider internal quality review purposes only. Providers should report numerator/denomonator as specified in the denominator inclusion and numerator inclusion sections so that the the numerator is the number of cases from the denominator that were a "Yes" or "NA" for all relevant subsections. Subsection scores should not be reported to HHSC.) Considerations for Electronic Transfer of Information:For health systems with shared electronic medical records, documentation must indicate that data elements had been entered into the data system and were available to the receiving facility prior to transfer forAdministrative Measures or within 60 minutes of discharge for all other measures. If there are not shared records, “sent” meansthat medical record documentation indicates the information went with the patient viafax, phone, or internet/Electronic Health Record. See specifications for detailed list of acceptable values/formats for data elements, a sample ED Transfer Communication Measure Data Collection Worksheet Numerator Collection (Cont'd)Data Element Name: Sensory Status (formerly Impairments)Suggested Data Collection Question: Does the medical record documentation indicate that the patient was assessed for impairments?AllowableValues:- Y (Yes) Select this option if there is documentation that assessment of sensory status was done and information was sent to the receiving facility.N (No) Select this option if there is no documentation that assessment of sensory status was done and information was sent to the receiving facility.Notes for Abstraction:- Select Yes if documentation indicates that patient is unresponsive.- Documentation includes the patient being assessed for mental, speech, hearing, vision, and sensation impairment.For example:- A History and Physical that includes at least one the following would be acceptable o ENT WNL – indicates assessment of speech and hearing o Oriented - indicates assessment of mental status o Has or denies tingling/numbness – indicates assessment of sensation- Nursing Notes that indicate the following would be acceptable: o Wears eyeglasses – indicates assessment of vision o Has hearing aid – indicates assessment of hearingSuggested Data Sources: Emergency Department record, Transfer Summary Data Element Name: Catheters/IVSuggested Data Collection Question: Does the medical record documentation indicate that treatment with IV or any other catheters was provided to the patient and sent to the receiving facility? AllowableValues:- Y (Yes) Select this option if there is documentation that catheter information was sent to the receiving facility.- N (No) Select this option if there is no documentation that catheter information was sent to the receiving facility.- NA (Not Applicable) Select this option if no catheters were placed.Notes for Abstraction:- Select NA if no catheters were placed.Suggested Data Sources: Emergency Department record, Transfer Summary documentInclusion Guidelines for Abstraction: IV (intravenous), IT (intrathecal), Urinary, Heparin Lock, Central line Data Element Name: ImmobilizationsSuggested Data Collection Question: Does the medical record documentation indicate information was sent regarding any immobilization provided for the patient?AllowableValues:- Y (Yes) Select this option if there is documentation that immobilization was done and information was sent to the receiving facility.- N (No) Select this option if there is documentation that immobilization was done and information was not sent to the receiving facility.- NA (Not Applicable) Select this option if no immobilization was doneNotes for Abstraction:- Select NA if no immobilization was done.Suggested Data Sources: Emergency Department record, Transfer Summary documentInclusion Guidelines for Abstraction: Backboard, Casts, Neck brace, Other braces Data Element Name: Respiratory SupportSuggested Data Collection Question: Does the medical record documentation indicate information was sent regarding any respiratory support provided to the patient?AllowableValues:- Y (Yes) Select this option if there is documentation that respiratory support was provided and information was sent to the receiving facility.- N (No) Select this option if documentation that respiratory support was provided and information was not sent to the receiving facility.- NA (Not Applicable) Select this option if no respiratory support was provided.Notes for Abstraction:- If no respiratory support was provided select NA.Suggested Data Sources: Emergency Department record, Transfer Summary documentInclusion Guidelines for Abstraction: Bronchial drainage, Intubations, Oxygen, Ventilator support Data Element Name: Oral RestrictionsSuggested Data Collection Question: Does the medical record documentation indicate information was sent regarding any oral restrictions placed on the patient?AllowableValues:- Y (Yes) Select this option if there is documentation that oral restriction were placed and information was sent to the receiving facility.- N (No) Select this option if there is documentation that oral restrictions were placed and information was not sent to the receiving facility.- NA (Not Applicable) Select this option if no oral restrictions were placed.Notes for Abstraction:- Select NA if no oral restrictions were placed.Suggested Data Sources: Emergency Department record, Transfer Summary documentInclusion Guidelines for Abstraction: NPO, Clear liquids, Soft diet, Low NA diet Data Element Name: Tests/Procedures PerformedSuggested Data Collection Question: Does the medical record documentation indicate information was sent on any tests and procedures done in the ED?AllowableValues:- Y (Yes) Select this option if there is documentation that information on all tests and procedures completed in the ED prior to transfer was sent to the receiving facility.- N (No) Select this option if there is no documentation that information on all tests and procedures completed in the ED prior to transfer was sent to the receiving facility.- NA (Not Applicable) Select this option if no tests or procedures were done.Notes for Abstraction:- If test or procedure results were sent select yes.- If no tests or procedures were done select NA.Suggested Data Sources: Emergency Department record, Lab documentation, Transfer Summary documentInclusion Guidelines for Abstraction: Lab work ordered, X-rays, Procedures performed, EKGs Data Element Name: Tests/Procedure ResultsSuggested Data Collection Question: Does the medical record documentation indicate that results were sent from completed tests and procedures done in the ED?AllowableValues:- Y (Yes) Select this option if there is documentation of results being sent either with the patient or communicated to the receiving facility when available.- N (No) Select this option if there is no documentation of results being sent either with the patient or communicated to the receiving facility when available.- NA (Not Applicable) Select this option if no tests or procedures were done.Notes for Abstraction:- If shared medical record then tests and procedures done and results are considered sent – select yes- If results not sent and no shared medical record then documentation must include a plan to communicate results – select yesSuggested Data Sources: Emergency Department record, Lab documentation, Transfer Summary documentInclusion Guidelines for Abstraction: Lab results, X-ray results, Procedure results ................
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