n Qf Care Coordination and Cr

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National Quality Forum

The mission o the National Quality Forum is to improve the quality o Americanhealthcare by setting national priorities and goals or perormance improvement,endorsing national consensus standards or measuring and publicly reporting onperormance, and promoting the attainment o national goals through education and outreach programs.

This work was supported by Sanof-aventis, WellPoint, and the Department o Veterans Aairs.

Recommended Citation: National Quality Forum (NQF), Preferred Practices and PerformanceMeasures for Measuring and Reporting Care Coordination: A Consensus Report,Washington, DC: NQF; 2010.

2010 National Quality Forum


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Preferred Practices and Performance Measures for Measuringand Reporting Care Coordination: A Consensus Report

ForewordCARE COORDINATION IS A VITAL ASPECT o health and healthcare services. When care ispoorly coordinatedwith inaccurate transmission o inormation, inadequate communication, andinappropriate ollow-up carepatients who see multiple physicians and care providers can acemedication errors, hospital readmissions, and avoidable emergency department visits. The eects opoorly coordinated care are particularly evident or people with chronic conditions such as diabetesand hypertension and those at high risk or multiple illnesses who oten are expected to navigatea complex healthcare system. Despite eorts to reduce problems through various initiatives andprogramssuch as care/case managementhealthcare is not currently delivered uniormly in awell-coordinated and efcient manner.

In 2006, the National Quality Forum (NQF), an organization dedicated to improving healthcarequality, endorsed a defnition o and ramework or care coordination. This ramework identifedfve key domains: Healthcare Home, Proactive Plan o Care and Follow-up, Communication,Inormation Systems, and Transitions or Handos. In addition to endorsing a defnition and rame-work, NQF, in its role as a convener and partner in the National Priorities Partnership (NPP), has

ocused on care coordination. Specifcally, the Partnership established the ollowing goals:Improve care and achieve quality by acilitating and careully considering eedback rom all

patients regarding coordination o their care;

Improve communication around medication inormation;


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Executive SummaryWe envision a healthcare system that guides patients and families through theirhealthcare experience, while respecting patient choice, offering physical andpsychological supports, and encouraging strong relationships between patient

and the healthcare professionals accountable for their care.

National Priorities Partnership, 2008

CARE COORDINATION IS A VITAL aspect o health and healthcare services. Manypatients oten see multiple physicians and care providers a year, which can lead to moreharm, disease burden, and overuse o services than i care were coordinated. This is par-ticularly evident or people with chronic conditions and those at high risk or comorbidities,

who oten are expected to navigate a complex healthcare system. Despite eorts to reduceproblems through various initiatives and programssuch as care/case managementpoor communication, medication errors, and preventable hospital readmissions are stillsubstantial


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Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination

This NQF report, Preferred Practices and Performance Measures for Measuring and ReportingCare Coordination: A Consensus Report, aims to promote care coordination across settings andproviders by endorsing a set o preerred practices and perormance measures (Table 1). Thesestandards address the domains o the NQF-endorsed Framework or Care Coordination and thegoals o the Partnership. Systematic implementation o these practices will improve the coordination

o patient care and healthcare quality.

Table 1: National Voluntary Consensus Standards or Care Coordination

Preerred Practices: Healthcare Home DomainPreferred Practice 1: The patient shall be provided the opportunity to select the healthcare home

that provides the best and most appropriate opportunities to the patient to develop and maintaina relationship with healthcare providers.

Preferred Practice 2: The healthcare home or sponsoring organizations shall be the central pointor incorporating strategies or continuity o care.

Preferred Practice 3: The healthcare home shall develop inrastructure or managing plans ocare that incorporate systems or registering, tracking, measuring, reporting, and improvingessential coordinated services.

Preferred Practice 4:The healthcare home should have policies, procedures, and accountabilities

to support eective collaborations between primary care and specialist providers, includingevidence-based reerrals and consultations that clearly defne the roles and responsibilities.

Preferred Practices 5: The healthcare home will provide or arrange to provide care coordinationservices or patients at high risk or adverse health outcomes high service use and high costs


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National Quality Forum


Preerred Practices: Communication DomainPreferred Practice 11: The patients plan o care should always be made available to the

healthcare home team, the patient, and the patients designees.

Preferred Practice 12: All healthcare home team members, including the patient and his orher designees, should work within the same plan o care and share responsibility or theircontributions to the plan o care and or achieving the patients goals.

Preferred Practice 13: A program should be used that incorporates a care partner to supportamily and riends when caring or a hospitalized patient.

Preferred Practice 14: The providers perspective o care coordination activities should beassessed and documented.

Preerred Practices: Inormation Systems DomainPreferred Practice 15: Standardized, integrated, interoperable, electronic, inormation systems

with unctionalities that are essential to care coordination, decision support, and qualitymeasurement and practice improvement should be used.

Preferred Practice 16: An electronic record system should allow the patients health inormationto be accessible to caregivers at all points o care.

Preferred Practice 17:Regional health inormation systems, which may be governed by variouspartnerships, including public/private, state/local agencies, should enable healthcare hometeams to access all patient inormation.


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Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination


Preferred Practice 23: Healthcare providers and healthcare organizations should implementprotocols and policies or a standardized approach to all transitions o care. Policies andprocedures related to transitions and the critical aspects should be included in the standardizedapproach.

Preferred Practice 24: Healthcare providers and healthcare organizations should have systems inplace to clariy, identiy, and enhance mutual accountability (complete/confrmed communicationloop) o each party involved in a transition o care.

Preferred Practice 25: Healthcare organizations should evaluate the eectiveness o transitionprotocols and policies, as well as evaluate transition outcomes.

Perormance Measures or Care CoordinationCardiac rehabilitation patient reerral rom an inpatient setting

Cardiac rehabilitation patient reerral rom an outpatient setting

Patients with a transient ischemic event ER visit who had a ollow-up ofce visit

Biopsy ollow-up

Reconciled medication list received by discharged patients (inpatient discharges to home/selcare or any other site o care)

Transition record with specifed elements received by discharged patients (inpatient dischargesto home/sel-care or any other site o care)

Timely transmission o transition record (inpatient discharges to home/sel care or any other site


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Appendix ASpecifcations o the National Voluntary ConsensusStandards or Care Coordination

THE FOLLOWING TABLE PRESENTS the detailed specifcations or the National Quality

Forum (NQF)-endorsedNational Voluntary Consensus Standards for Care Coordination.All inormation presented has been derived directly rom measure sources/developerswithout modifcation or alteration (except when the measure developer agreed to suchmodifcation during the NQF Consensus Development Process) and is current as oDecember 2009. All NQF-endorsed voluntary consensus standards are open source,meaning they are ully accessible and disclosed.


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Appendix A Specifcations o the National Voluntary Consensus Standards or Care Coordination

MEASURE TITLEMEASURENUMBERS

MEASURESTEWARD

a NUMERATOR

DENOMINATOR

EXCLUSIONS DATA SOURCE

Cardiacrehabilitationpatientreerral rom aninpatient setting

Measure ID #:0642

Review #:CC-019-09

ACCF/AHATask Force

Numerator StatementNumber o eligible patients with aqualiying event/diagnosis who havebeen reerred to an outpatient cardiacrehabilitation program prior to hospitaldischarge, or who have a documentedmedical or patient-oriented reason whysuch a reerral was not made.

(Note: the program may include atraditional program based on ace-to-

ace interactions or training sessionsor may include other options such ashome-based approaches. I alterna-tive methods are used, they should bedesigned to meet appropriate saetystandards.)

Numerator DetailsA reerral is defned as an ofcialcommunication between the healthcareprovider and the patient to recommendand carry out a reerral order to anearly outpatient cardiac rehabilitationprogram. This includes the provision oall necessary inormation to the patientthat will allow the patient to enroll in

Denominator StatementAll hospitalized patients in the reportingperiod hospitalized with a qualiyingcardiovascular disease event who do notmeet any o the exclusion criteria.

Denominator DetailsQualiying cardiovascular disease eventsincluding the ollowing: (1) Acute myocardialinarction (defned by standardizedcriteria on the basis o cardiac pain,

electrocardiographic data, and biomarkerlevels, (2) Coronary artery bypass grat(CABG) surgery, (3) Chronic stable angina(characterized as a deep, poorlylocalized chest or arm discomort thatis reproducibly associated with physicalexertion or emotional stress and is relievedpromptly (i.e., less than 5 minutes) with restand/or the use o sublingual nitroglycerin(NTG)) , (4) Cardiac valve surgery (surgicalrepair or replacement o the aortic, mitral,

pulmonic or tricuspid valves), and (5)Cardiac transplantation.

Denominator ExclusionsExclusion criteria includedocumentation o one omore o the ollowingbarriers to cardiac rehabilitationparticipation: (1) Patient actors(patient to be discharged to anursing care acility or long-term care, or example),(2) Medical actors (patientdeemed by provider to have

a medically unstable, lie-threatening condition, orexample), (3) Healthcaresystem actors (no cardiacrehabilitation program available

within 60 minutes o travel timerom the patients home, orexample).

ElectronicHealth/MedicalRecord

ElectronicClinicalRegistry- NationalCardiovascularData Registry(NCDR),ACTION-GetWith theGuidelinesInpatientRegistry

Electronic Claims

Paper MedicalRecord

a Measure Steward(s). For the most current specifcations and supporting inormation, please reer to the Measure Steward:

AAD - American Academy o Dermatology (www.aad.org)ACCF (American College o Cardiology Foundation)/AHA (American Heart Association) Task Force (www.americanheart.org)AMA PCPI - American Medical Association (AMA)-convened Physician Consortium or Perormance Improvement (www.ama-assn.org)Ingenix (www.ingenix.com)NCQANational Committee or Quality Assurance (www.ncqa.org)

more

National Quality Forum A-2
http://www.aad.org/http://www.americanheart.org/http://www.ama-assn.org/http://www.ingenix.com/http://www.ncqa.org/http://www.ncqa.org/http://www.ingenix.com/http://www.ama-assn.org/http://www.americanheart.org/http://www.aad.org/


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MEASURESTEWARD

a NUMERATOR

DENOMINATOR


Cardiacrehabilitationpatientreerral rom aninpatient setting

(continued)

an early outpatient cardiac rehabilita-tion program. This also includes writtenor electronic communication betweenthe healthcare provider or healthcaresystem and the cardiac rehabilitationprogram that includes the patientsenrollment inormation or theprogram. A hospital discharge sum-mary or ofce note may be potentiallyormatted to include the necessarypatient inormation to communicate

to the cardiac rehabilitation program[the patients cardiovascular history,testing, and treatments, or instance].All communications must maintainappropriate confdentiality as outlinedby the 1996 Health InsurancePortability and Accountability Act(HIPAA).

Detailed specifcations and coding areavailable atwww.qualityorum.org/

projects/care_coordination.aspx.

Patients with a qualiying event who are tobe discharged or a short-term stay in aninpatient medical rehabilitation acilityare still expected to be reerred to anoutpatient cardiac rehabilitation programby the in-patient team during the indexhospitalization. This reerral should bereinorced by the care team at the medicalrehabilitation acility.

Detailed specifcations and coding are

available atwww.qualityorum.org/projects/care_coordination.aspx.

more
http://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspx


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MEASURESTEWARD

a NUMERATOR

DENOMINATOR


Cardiacrehabilitationpatient reerralrom anoutpatientsetting

Measure ID #:0643

Review #:CC-020-09

ACCF/AHATask Force Numerator StatementNumber o patients in an outpatientpractice who have had a qualiyingevent/diagnosis in the previous 12months who have been reerred toan outpatient cardiac rehabilitation/secondary prevention program.

(Note: the program may include atraditional program based on ace-to-ace interactions or training sessions

or may include other options such ashome-based approaches. I alterna-tive methods are used, they should bedesigned to meet appropriate saetystandards.)

Numerator DetailsA reerral is defned as an ofcialcommunication between the healthcareprovider and the patient to recommendand carry out a reerral order to anearly outpatient cardiac rehabilitationprogram. This includes the provisiono all necessary inormation to thepatient that will allow the patient toenroll in an early outpatient cardiacrehabilitation program. This alsoincludes written or electronic communi-cation between the healthcare provideror healthcare system and the cardiac

Denominator StatementNumber o patients in an outpatientclinical practice who have had aqualiying cardiovascular event in theprevious 12 months, who do not meetany o the exclusion criteria, and whohave not participated in an outpatientcardiac rehabilitation program since thecardiovascular event.

Denominator DetailsQualiying cardiovascular disease events

including the ollowing: (1) Acute myocardialinarction (defned by standardizedcriteria on the basis o cardiac pain,electrocardiographic data, and biomarkerlevels), (2) Coronary artery bypass grat(CABG) surgery, (3) chronic stable angina(characterized as a deep, poorly localizedchest or arm discomort that is reproduciblyassociated with physical exertion oremotional stress and is relieved promptly(i.e., less than 5 minutes) with rest and/or

the use o sublingual nitroglycerin (NTG)) ,(4) Cardiac valve surgery (surgical repair orreplacement o the aortic, mitral, pulmonicor tricuspid valves), and (5) cardiactransplantation.

Detailed specifcations and coding areavailable atwww.qualityorum.org/projects/care_coordination.aspx.

Denominator ExclusionsExclusion criteria includedocumentation o one omore o the ollowing barriersto cardiac rehabilitationparticipation: (1) Patient actors(patient resides in a long-term nursing care acility, orexample), (2) Medical actors(patient deemed by providerto have a medically unstable,

lie-threatening condition),(3) Healthcare system actors(no cardiac rehabilitationprogram available within 60minutes o travel time rom thepatients home, or example).

The outpatient setting wherethis measure would applyincludes the outpatientpractice setting o the clinician

who provides the primary

cardiovascular-related care orthe patient.

In general, this would be thepatients cardiologist, but insome cases it might be a amilyphysician, internist, nursepractitioner, or other healthcareprovider.

ElectronicHealth/MedicalRecord

ElectronicClinical Registry- NationalCardiovascularData Registry(NCDR),ACTION-GetWith theGuidelinesInpatientRegistry

Electronic Claims

Paper MedicalRecord

more
http://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspx


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MEASURESTEWARD

a NUMERATOR

DENOMINATOR


Cardiacrehabilitationpatient reerralrom anoutpatientsetting

(continued)

rehabilitation program that includesthe patients enrollment inormation orthe program. A hospital discharge sum-mary or ofce note may be potentiallyormatted to include the necessarypatient inormation to communicateto the cardiac rehabilitation program[the patients cardiovascular history,testing, and treatments, or instance.]According to standards o practice orcardiac rehabilitation programs, care

coordination communications are sentto the reerring provider, including anyissues regarding treatment changes,adverse treatment responses, ornew non-emergency condition (newsymptoms, patient care questions, etc.)that need attention by the reerringprovider. These communications alsoinclude a progress report once thepatient has completed the program.All communications must maintain ap-propriate confdentiality as outlined bythe 1996 Health Insurance Portabilityand Accountability Act (HIPAA).

Detailed specifcations and coding areavailable atwww.qualityorum.org/projects/care_coordination.aspx.

more
http://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspxhttp://www.qualityforum.org/projects/care_coordination.aspx


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MEASURESTEWARD

a NUMERATOR

DENOMINATOR


Patients witha transientischemic eventER visit thathad a ollow-upofce visit

Measure ID #:0644

Review #:CC-050-09

Ingenix Numerator StatementCreate a POST period rom the dayater the initiating Facility Event (i.e.,the ER encounter or the transientcerebral ischemic event) through14 days ater the initiating FacilityEvent

AND

During the POST period, did the patienthave any proessional encounter

(code set PR0107, RV0107) with anydiagnosis.

Note: Will allow non-physicianencounters (e.g., nurse practitionerand physician assistance encounters) tocount toward numerator compliance aslong as the provider(s) has submittedone o the ace-to-ace encounter codes(e.g., 99213) listed in our code set.

Numerator Details

Seewww.qualityorum.org/projects/care_coordination.aspx.

Denominator StatementFor condition confrmation, patients mustmeet the ollowing criteria:

1. All males or emales that are 18 years orolder at the end o the report period

2. Patient must have been continuouslyenrolled:

Medical benefts throughout the 12 monthsprior to the end o the report period

ANDPharmacy beneft plan or 6 months prior tothe end o the report period

Note: The standard enrollment break logicallows unlimited breaks o no more than 45days and no breaks greater than 45 days.

3. Either one o the ollowing (A or B):

A. The patient is listed on the Disease Regis-try Input File or this condition, i a Disease

Registry Input File is available. Note: DiseaseRegistry is NOT a required input fle.

B. During the 24 months prior to the endo the report period, patient has 2 or morethat are at least 14 days apart o theollowing services, where the diagnosis isOcclusive Vascular Disease OR Stroke,non-hemorrhagic OR Transient cerebral

Denominator ExclusionsNone

Electronic Claims

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MEASURESTEWARD

a NUMERATOR

DENOMINATOR


Patients witha transientischemic eventER visit thathad a ollow-upofce visit

(continued)

ischemia (code set DX0110, DX0146,DX0149):

Proessional Encounter (code set PR0107,RV0107)

Proessional Supervision (code setPR0108)

Facility Event Confnement/Admission

Facility Event Emergency Room

Facility Event Outpatient Surgery

In addition, or this measure, the patientmust meet the ollowing criteria:

Create multiple temporary events ortransient cerebral ischemic event.

Set Episode Start Date to the date o serviceo any claim (i.e., initiating event) or theservice and diagnosis stated below duringthe ollowing window o time: 365 daysprior to the end o the report period through30 days prior to the end o the report period

Facility Event Emergency Room AND

The primary diagnosis on the claim was:Transient cerebral ischemia (code setDX0149).

Denominator DetailsSeewww.qualityorum.org/projects/care_coordination.aspx.

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MEASURE MEASUREMEASURE TITLE NUMBERS STEWARD

aNUMERATOR DENOMINATOR EXCLUSIONS DATA SOURCE

Biopsy ollow-up Measure ID #: AAD Numerator Statement Denominator Statement Denominator Exclusions

Paper Medical0645 Patients who are undergoing a All patients undergoing a biopsy. Patients not undergoing a Recordbiopsy whose biopsy results have been biopsy

Review #: Denominator Detailsreviewed by the biopsying physician

CC-071-09 2P Biopsy results not communicated withand communicated to the primary care

primary care physician due to patient reusalphysician and the patient, denoted byentering said physicians initials into a 3P Biopsy not entered into log due tolog, as well as by documentation in the system reasonspatients medical record. 8P Reason not otherwise specifed.Numerator Details Biopsy Procedure CPT codes:

Not available at this time 11100, 11101, 11755, 19100, 19101,19102, 19103, 19295,

20200, 20205, 20206, 20220, 20250,20251, 21550, 21920, 21925, 23065,23066, 23100, 23101, 23105, 23106,24065, 24066, 24100, 24101, 25065,25066, 25100, 25101, 26100, 26105,26110, 27040, 27041, 27050, 27052,27323, 27324, 27330, 27331, 27613,27614, 28050, 28052, 28054,

30100, 31050, 31051, 31237, 31510,31576, 31625, 31628, 31629, +31632,+31633, 31717, 32095, 32100, 32400,32402, 32405, 37200, 38500, 38505,38510, 38520, 38525, 38530, 38570,38571, 38572, 38792, 39400 37609,38221,

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Biopsy ollow-up 40808, 41100-41105, 41108, 40490,42100, 42405, 42800, 42802, 42804,(continued)42806, 44010, 44020, 44100, 43202,43600-43605, 44322, 43261, 43239,44361, 44377, 44382, 44389, 44025,45100, 45305, 45331, 45380, 45391,45392, 46606, 47000, 47001, 47100,47553, 47561, 48100, 49000, 49010,

50200, 50205, 50555, 50557, 50574,50576, 50955, 50957, 50974, 50976,52204, 52224, 52250, 52354, 53200,54100, 54105, 54500, 54505, 54800,54865, 55700, 55705, 55706, 56605,+56606, 56821, 57100, 57105, 57421,58100, +58110, 58558, 58900, 59015,

60100, 60540, 60545, 61140, 61332,61575, 61576, 61750, 61751, 62269,63275, 63276, 63277, 63278, 63280,63281, 63282, 63283, 63285, 63286,63287, 63290, 63615, 65410, 67400,67415, 67450, 67810, 68100, 69100,

69105,

89290, 89291,

93505

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Reconciled Measure ID #: AMA PCPI Numerator Statement Denominator Statement Denominator Exclusions

Electronicmedication list 0646 Patients or their caregiver(s) who All patients, regardless o age, discharged Patients who died. Health/Medicalreceived by received a reconciled medication list at rom an inpatient acility (e.g., hospital Record

Review #: Patients who let againstdischarged the time o discharge including, at a inpatient or observation, skilled nursing Paper MedicalCC-073-09 medical advice (AMA) orpatients minimum, medications in the ollowing acility, or rehabilitation acility) to home/ Recorddiscontinued care.(inpatient categories: sel care or any other site o care.

Hybrid,discharges to

Medications to be TAKEN by patient: Denominator Details electronichome/sel care

The denominator may be identifed using data collection Continued*or any otherUB-04 claims data: supplementedMedications prescribed beore inpatientsite o care)

with medicalstay that patient should continue to UB-04 (Form Locator 04 - Type o Bill):record

take ater discharge, including any 0111 (Hospital, Inpatient, Admit through abstractionchange in dosage or directions Discharge Claim)AND

0121 (Hospital, Inpatient - Medicare Part New* B only, Admit through Discharge Claim)Medications started during inpatient 0114 (Hospital, Inpatient, Last Claim)stay that are to be continued ater

0124 (Hospital, Inpatient - Medicare Partdischarge and newly prescribed

B only, Interim - Last Claim)medications that patient should begin

0211 (Skilled Nursing - Inpatient, Admittaking ater discharge.through Discharge Claim)

*Prescribed dosage, instructions, and 0214 (Skilled Nursing - Inpatient, Interim,

intended duration must be included or Last Claim)each continued and new medicationlisted. 0221 (Skilled Nursing - Inpatient, Medi-

care Part B only, Admit through DischargeMedications NOT to be taken by

Claim)patient:

0224 (Skilled Nursing - Interim, Last Discontinued

Claim)Medications taken by patient beore

0281 (Skilled Nursing - Swing Beds,the inpatient stay that should beAdmit through Discharge Claim)discontinued or held ater discharge,

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aNUMERATOR DENOMINATOR EXCLUSIONS

Reconciled AND

0284 (Skilled Nursing - Swing Beds,medication list Interim, Last Claim) Allergies and Adverse Reactionsreceived by Medications administered during the ANDdischarged inpatient stay that caused an allergic Discharge Status (Form Locator 17):patients reaction or adverse event and were

01 (Discharged to home care or sel care(inpatient thereore discontinued.(routine discharge)discharges to

Time Window: Each time a patient ishome/sel care 02 (Discharged/transerred to a short-

discharged rom an inpatient acility.or any other term general hospital or inpatient care)site o care) Numerator Details 03 (Discharged/transerred to skilled

Numerator details to be obtained(continued) nursing acility (SNF) with Medicare

through medical record abstraction. certifcation in anticipation o skilled care)See Retrospective data collection tool

04 (Discharged/transerred to anin measure worksheet document or

intermediate-care acility)numerator details.

05 Discharged/transerred to a desig-Defnitions specifc to Measure #XXXX: nated cancer center or childrens hospital For the purposes o this measure, 06 (Discharged/transerred to home

medications includes prescrip- under care o organized home healthtion, over-the-counter, and herbal service org. in anticipation o coveredproducts. Generic and proprietary skilled care)names should be provided or each

43 (Discharged/transerred to a ederalmedication, when available. healthcare acility)

Given the complexity o the medica- 50 (Hospice home)

tion reconciliation process and vari- 51 (Hospice - medical acility (certifed)ability across inpatient acilities in

providing hospice level o care)documentation o that process, thismeasure does not require that the 61 (Discharged/transerred to hospital-medication list be organized under based Medicare-approved swing bed)the Taken/NOT taken headingsOR the specifed sub-categories,

DATA SOURCE

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MEASURESTEWARD

a NUMERATOR

DENOMINATOR


Reconciledmedication listreceived bydischargedpatients(inpatientdischarges tohome/sel careor any othersite o care)

(continued)

provided that the status o eachmedication (continued, new, ordiscontinued) is specifed within thelist AND any allergic reactions areidentifed.

Detailed specifcations with coding canbe ound at http://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pd.

62 (Discharged/transerred to aninpatient rehabilitation acility (IRF)including rehabilitation distinct part unitso a hospital)

63 (Discharged/transerred to aMedicare-certifed long-term care hospital(LTCH))

64 (Discharged/transerred to a nursingacility certifed under Medicaid but notcertifed under Medicare)

65 (Discharged/transerred to a psychiat-ric hospital or psychiatric distinct part unito a hospital)

66 (Discharged/transerred to a CriticalAccess Hospital (CAH))

70 (Discharged/transerred to anothertype o healthcare institution not defnedelsewhere in this code list)

OR

UB-04 (Form Locator 04 - Type o Bill):

0131 (Hospital Outpatient, Admit throughDischarge Claim)

0134 (Hospital Outpatient, Interim, LastClaim)

AND

UB-04 (Form Locator 42 - Revenue Code):

0762 (Hospital Observation)

more
http://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdfhttp://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pdf


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Reconciled

0490 (Ambulatory Surgery)medication list 0499 (Other Ambulatory Surgery)received by

ANDdischarged

Discharge Status (Form Locator 17):patients(inpatient 01 (Discharged to home care or sel caredischarges to (routine discharge)home/sel care 02 (Discharged/transerred to a short-or any other term general hospital or inpatient care)site o care)

03 (Discharged/transerred to skilled(continued) nursing acility (SNF) with Medicare certi-

fcation in anticipation o skilled care)

04 (Discharged/transerred to anintermediate-care acility)

05 Discharged/transerred to a desig-nated cancer center or childrens hospital

06 (Discharged/transerred to homeunder care o organized home healthservice org. in anticipation o coveredskilled care)

43 (Discharged/transerred to a ederalhealthcare acility)

50 (Hospice - home)

51 (Hospice - medical acility (certifed)providing hospice level o care)

61 (Discharged/transerred to hospital-based Medicare-approved swing bed)

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Reconciled

62 (Discharged/transerred to anmedication list inpatient rehabilitation acility (IRF)received by including rehabilitation distinct part unitsdischarged o a hospital)patients 63 (Discharged/transerred to a(inpatient Medicare-certifed long-term care hospitaldischarges to (LTCH))home/sel care

64 (Discharged/transerred to a nursingor any other

acility certifed under Medicaid but notsite o care)

certifed under Medicare)(continued)

65 (Discharged/transerred to apsychiatric hospital or psychiatric distinctpart unit o a hospital)


70 (Discharged/transerred to anothertype o healthcare institution not defnedelsewhere in this code list).

Detailed specifcations with coding can beound at http://www.ama-assn.org/

ama1/pub/upload/mm/370/care-transitions-ms.pd.

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Transition record Measure ID #: AMA PCPI Numerator Statement Denominator Statement Denominator Exclusions

Electronicwith specifed 0647 Patients or their caregiver(s) who All patients, regardless o age, discharged Patients who died. Health/Medicalelements received a transition record (and with rom an inpatient acility (e.g., hospital Record

Review #: Patients who let againstreceived by whom a review o all included inorma- inpatient or observation, skilled nursing Paper MedicalCC-074-09 medical advice (AMA) ordischarged tion was documented) at the time o acility, or rehabilitation acility) to home/ Recorddiscontinued care.patients discharge including, at a minimum, all sel care or any other site o care.

Hybrid,(inpatient o the ollowing elements:

Time Window: Each time a patient is electronicdischarges to

Inpatient Care: discharged rom an inpatient acility. data collectionhome/sel care

supplemented Reason or inpatient admission, ANDor any other Denominator Detailswith medical

site o care) Major procedures and tests UB-04 (Form Locator 04 - Type o Bill):record

perormed during inpatient stay and 0111 (Hospital, Inpatient, Admit through abstractionsummary o results, AND Discharge Claim)

Principal diagnosis at discharge 0121 (Hospital, Inpatient - Medicare PartB only, Admit through Discharge Claim)Post-Discharge/Patient Sel-

Management: 0114 (Hospital, Inpatient, Last Claim)

Current medication list, AND 0124 (Hospital, Inpatient - Medicare PartB only, Interim - Last Claim) Studies pending at discharge (e.g.,

laboratory, radiological), AND 0211 (Skilled Nursing - Inpatient, Admitthrough Discharge Claim) Patient instructions

0214 (Skilled Nursing - Inpatient, Interim,Advance Care Plan: Last Claim) Advance directives or surrogate

0221 (Skilled Nursing - Inpatient,decision maker documented OR

Medicare Part B only, Admit through Documented reason or not Discharge Claim)

providing advance care plan 0224 (Skilled Nursing - Interim,

Contact Inormation/Plan or Last Claim)Follow-up Care:

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Transition record

24-hour/7-day contact inormation

0281 (Skilled Nursing - Swing Beds,with specifed including physician or emergencies Admit through Discharge Claim)elements related to inpatient stay, AND 0284 (Skilled Nursing - Swing Beds,received by Contact inormation or obta in- Interim, Last C la im)discharged ing results o studies pending at

ANDpatients discharge, AND(inpatient Discharge Status (Form Locator 17):

Plan or ollow-up care, ANDdischarges to 01 (Discharged to home care or sel care

Primary physician, other health carehome/sel care (routine discharge)proessional, or site designated oror any other

02 (Discharged/transerred to aollow-up care.site o care) short-term general hospital or inpatient(continued) Time Window: Each time a patient is care)

discharged rom an inpatient acility. 03 (Discharged/transerred to skilled

Numerator Details: nursing acility (SNF) with MedicareNumerator details to be obtained certifcation in anticipation o skilled care)through medical record abstraction. 04 (Discharged/transerred to anSee Retrospective data collection tool intermediate-care acility)in measure worksheet document or

05 Discharged/transerred to anumerator details.

designated cancer center or childrensDefnitions specifc to Measure #XXXX: hospital

a. Transition record: a core, standard-

06 (Discharged/transerred to homeized set o data elements related to under care o organized home healthpatients diagnosis, treatment, and care service org. in anticipation o coveredplan that is discussed with and provided skilled care)to patient in a printed or electronic 43 (Discharged/transerred to a ederalormat at each transition o care, and healthcare acility)transmitted to the acility/physician/

50 (Hospice - home)other healthcare proessional providingollow-up care. Electronic ormat may

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Transition record be provided only i acceptable to

51 (Hospice - medical acility (certifed)with specifed patient. providing hospice level o care)elements 61 (Discharged/transerred to hospital-b. Current medication list: all medica-received by based Medicare- approved swing bed)tions to be taken by patient aterdischarged

discharge, including all continued and 62 (Discharged/transerred to anpatients

new medications. inpatient rehabilitation acility (IRF)(inpatient

including rehabilitation distinct part unitsdischarges to c. Advance directives: e.g., written

o a hospital)home/sel care statement o patient wishes regarding

63 (Discharged/transerred to aor any other uture use o lie-sustaining medicalMedicare-certifed long- term caresite o care) treatment.

hospital (LTCH))(continued) d. Documented reason or not provid- 64 (Discharged/transerred to a nursing

ing advance care plan: documentationacility certifed under Medicaid but not

that advance care plan was discussedcertifed under Medicare)

but patient did not wish or was not able 65 (Discharged/transerred to ato name a surrogate decisionmaker

psychiatric hospital or psychiatric distinctor provide an advance care plan, ORpart unit o a hospital)documentation as appropriate that

the patients cultural and/or spiritual 66 (Discharged/transerred to a Criticalbelies preclude a discussion o advance Access Hospital (CAH))care planning as it would be viewed 70 (Discharged/transerred to another

as harmul to the patients belies and type o healthcare institution not defnedthus harmul to the physician-patient elsewhere in this code list)relationship.

UB-04 (Form Locator 04 - Type o Bill):e. Contact inormation/plan or ollow-

0131 (Hospital Outpatient, Admit throughup care: or patients discharged to an

Discharge Claim)inpatient acility, the transition record

0134 (Hospital Outpatient, Interim,may indicate that these our elementsLast Claim)are to be discussed between the

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Transition record discharging and the receiving ANDwith specifed acilities. UB-04 (Form Locator 42 - Revenue Code):elements

. Plan or ollow-up care: may 0762 (Hospital Observation)received by

include any postdischarge therapy 0490 (Ambulatory Surgery)dischargedneeded (e.g., oxygen therapy, physical

patients 0499 (Other Ambulatory Surgery)therapy, occupational therapy), any

(inpatient ANDdurable medical equipment needed,discharges to

amily/psychosocial resources available Discharge Status (Form Locator 17):home/sel care

or patient support, etc. 01 (Discharged to home care or sel careor any other(routine discharge)site o care) g. Primary physician or other health-

care proessional designated or ollow-

02 (Discharged/transerred to a short-(continued)up care: may be designated primary term general hospital or inpatient care)care physician (PCP), medical specialist, 03 (Discharged/transerred to skilledor other physician or healthcare nursing acility (SNF) with Medicareproessional. certifcation in anticipation o skilled care)

Detailed specifcations with coding can 04 (Discharged/transerred to anbe ound at http://www.ama- intermediate-care acility)assn.org/ama1/pub/upload/ 05 Discharged/transerred to amm/370/care-transitions-ms. designated cancer center or childrenspd. hospital

06 (Discharged/transerred to homeunder care o organized home healthservice org. in anticipation o coveredskilled care)


50 (Hospice - home)

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Transition record

51 (Hospice - medical acility (certifed)with specifed providing hospice level o care)elements 61 (Discharged/transerred to hospital-received by based Medicare- approved swing bed)discharged

62 (Discharged/transerred to anpatients

inpatient rehabilitation acility (IRF)(inpatient

including rehabilitation distinct part unitsdischarges to

o a hospital)home/sel care

63 (Discharged/transerred to aor any otherMedicare-certifed long-term care hospitalsite o care)

(LTCH))(continued) 64 (Discharged/transerred to a nursing

acility certifed under Medicaid but notcertifed under Medicare)



70 (Discharged/transerred to another

type o healthcare institution not defnedelsewhere in this code list).

Detailed specifcations with coding can beound at http://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pd.

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Timely Measure ID #: AMA PCPI Numerator Statement Denominator Statement Denominator Exclusions

Electronictransmission 0648 Patients or whom a transition record All patients, regardless o age, discharged Patients who died. Health/Medicalo transition was transmitted to the acility or rom an inpatient acility (eg, hospital Record

Review #: Patients who let againstrecord (inpatient primary physician or other healthcare inpatient or observation, skilled nursing Paper MedicalCC-075-09 medical advice (AMA) ordischarges to proessional designated or ollow-up acility, or rehabilitation acility) to home/ Recorddiscontinued care.home/sel care care within 24 hours o discharge. sel care or any other site o care.

Hybrid,or any other

Time Window: Each time a patient is Time Window: Each time a patient is electronicsite o care

discharged rom an inpatient acility. discharged rom an inpatient acility. data collectionsupplemented

Numerator Details Denominator Detailswith medical

Numerator details to be obtained UB-04 (Form Locator 04 - Type o Bill):record

through medical record abstraction. 0111 (Hospital, Inpatient, Admit through abstractionSee Retrospective data collection tool Discharge Claim)in measure worksheet document or

0121 (Hospital, Inpatient - Medicare Partnumerator details.

B only, Admit through Discharge Claim)Defnitions specifc to Measure #XXXX: 0114 (Hospital, Inpatient, Last Claim)a. Transition record: a core, standard- 0124 (Hospital, Inpatient - Medicare Partized set o data elements related to B only, Interim - Last Claim)patients diagnosis, treatment, and care

0211 (Skilled Nursing - Inpatient, Admitplan that is discussed with and provided

through Discharge Claim)to patient in a printed or electronic

0214 (Skilled Nursing - Inpatient, Interim,ormat at each transition o care, and Last Claim)transmitted to the acility/physician/other healthcare proessional providing 0221 (Skilled Nursing - Inpatient,ollow-up care. Electronic ormat may Medicare Part B only, Admit throughbe provided only i acceptable to Discharge Claim)patient. 0224 (Skilled Nursing - Interim,

Last Claim)

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Timely b. Transmitted: transition record

0281 (Skilled Nursing - Swing Beds,transmission may be transmitted to the acility or Admit through Discharge Claim)o transition physician or other healthcare 0284 (Skilled Nursing - Swing Beds,record (inpatient proessional designated or ollow-up Interim, Last Claim)discharges to care via ax, secure e-mail, or mutual

ANDhome/sel care access to an electronic health record

Discharge Status (Form Locator 17):or any other (EHR).site o care 01 (Discharged to home care or sel care

c. Primary physician or other(routine discharge)(continued) healthcare proessional designated

02 (Discharged/transerred to a short-or ollow-up care: may be designatedterm general hospital or inpatient care)primary care physician (PCP), medical

specialist, or other physician or 03 (Discharged/transerred to skilledhealthcare proessional. nursing acility (SNF) with Medicare

certifcation in anticipation o skilled care)Detailed specifcations with coding can

04 (Discharged/transerred to anbe ound at http://www.ama-intermediate-care acility)assn.org/ama1/pub/upload/

mm/370/care-transitions-ms. 05 (Discharged/transerred to a desig-pd nated cancer center or childrens hospital)

06 (Discharged/transerred to homeunder care o organized home healthservice org. in anticipation o covered

skilled care) 43 (Discharged/transerred to a ederal

healthcare acility)

50 (Hospice - home)


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Timely

61 (Discharged/transerred to hospital-transmission based Medicare-approved swing bed)o transition 62 (Discharged/transerred to anrecord (inpatient inpatient rehabilitation acility (IRF)discharges to including rehabilitation distinct part unitshome/sel care o a hospital)or any other

63 (Discharged/transerred to asite o care Medicare-certifed long-term care hospital(continued) (LTCH))

64 (Discharged/transerred to a nursing


65 (Discharged/transerred to a psychiat-ric hospital or psychiatric distinct part unito a hospital)


70 (Discharged/transerred to anothertype o healthcare institution not defnedelsewhere in this code list)

ORUB-04 (Form Locator 04 - Type o Bill):

0131 (Hospital Outpatient, Admit throughDischarge Claim)

0134 (Hospital Outpatient, Interim,Last Claim)

AND

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Timely UB-04 (Form Locator 42 - Revenue Code):transmission 0762 (Hospital Observation)o transition

0490 (Ambulatory Surgery)record (inpatient

0499 (Other Ambulatory Surgery)discharges tohome/sel care ANDor any other Discharge Status (Form Locator 17):site o care

01 (Discharged to home care or sel care(continued) (routine discharge)

02 (Discharged/transerred to a short-term general hospital or inpatient care)

03 (Discharged/transerred to skillednursing acility (SNF) with Medicarecertifcation in anticipation o skilled care)

04 (Discharged/transerred to anintermediate-care acility)

05 (Discharged/transerred to a desig-nated cancer center or childrens hospital)

06 (Discharged/transerred to homeunder care o organized home health

service org. in anticipation o coveredskilled care)


50 (Hospice - home)


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Timely

61 (Discharged/transerred to hospital-transmission based Medicare-approved swing bed)o transition 62 (Discharged/transerred to anrecord (inpatient inpatient rehabilitation acility (IRF)discharges to including rehabilitation distinct part unitshome/sel care o a hospital)or any other

63 (Discharged/transerred to asite o care

Medicare-certifed long-term care hospital(continued) (LTCH))

64 (Discharged/transerred to a nursing




70 (Discharged/transerred to anothertype o healthcare institution not defnedelsewhere in this code list).

Detailed specifcations with coding can beound at http://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pd.

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Transition record Measure ID #: AMA PCPI Numerator Statement Denominator Statement Denominator Exclusions

Electronicwith specifed 0649 Patients or their caregiver(s) who All patients, regardless o age, discharged Patients who died. Health/Medicalelements received a transition record at the rom an emergency department (ED) to Record

Review #: Patients who let againstreceived by time o emergency department (ED) ambulatory care (home/sel care) or home Paper MedicalCC-076-09 medical advice (AMA) ordischarged discharge including, at a minimum, all health/ Recorddiscontinued care.patients o the ollowing elements:

Denominator Details Hybrid,(emergency Patients who declined receipt o

Major procedures and tests UB-04 (Form Locator 4 - Type o Bill): electronicdepartment transition record.

perormed during ED visit, AND data collection 0131 (Hospital, Outpatient, Admitdischarges tosupplemented Principal diagnosis at discharge OR through Discharge Claim)ambulatory

with medicalchie complaint, ANDcare [home/sel ANDrecord

care])

Patient instructions, AND UB-04 (Form Locator 42 - Revenue Code): abstraction Plan or ollow-up care (OR state- 0450 (Emergency Room)

ment that none required), includingAND

primary physician, other healthcareUB-04 (Form Locator 17 - Discharge Status):proessional, or site designated or

ollow-up care, AND 01 (Discharged to home care or sel care(routine discharge))

List o new medications and changesto continued medications that pa- 06 (Discharged/transerred to hometient should take ater ED discharge, under care o organized home health

with quantity prescribed and/or service org. in anticipation o covered

dispensed (OR intended duration)skilled care).

and instructions or each. Detailed specifcations with coding can beNumerator Details ound at http://www.ama-assn.org/Numerator details to be obtained ama1/pub/upload/mm/370/care-through medical record abstraction. transitions-ms.pd.See Retrospective data collection toolin measure worksheet document ornumerator details.

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Transition record Defnitions specifc to Measure #XXXX:with specifed a. Transition record (or ED discharges):elements a core, standardized set o datareceived by elements related to patients diagno-discharged sis, treatment, and care plan that ispatients discussed with and provided to patient(emergency in written, printed, or electronic ormat.department Electronic ormat may be provided onlydischarges to i acceptable to patient.ambulatory b. Primary physician or othercare [home/sel healthcare proessional designated

care]) or ollow-up care: may be primary(continued) care physician (PCP), medical specialist,

or other physician or health careproessional. I no physician, otherhealthcare proessional, or sitedesignated or available, patient maybe provided with inormation onalternatives or obtaining ollow-upcare needed, which may include a listo community health services/otherresources.

Detailed specifcations with coding canbe ound at http://www.ama-assn.org/ama1/pub/upload/mm/370/care-transitions-ms.pd.

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MelanomaMeasure ID #: AMA PCPI/

Numerator Statement Denominator Statement Denominator Exclusions Claims

continuity o care 0650 AAD/NCQA Patients whose inormation is entered, All patients with a current diagnosis o Documentation o system Medical Record recall system at least once within a 12-month period, melanoma or a history o melanoma. reason(s) or not entering

Review #: Electronicinto a recall system* that includes: patients into a recall systemCC-078-09 Denominator Details Health/Medical

A target date or the next complete (e.g., melanoma beingAll patients, regardless o age, with a Recordphysical skin exam, AND monitored by another provider):current diagnosis o melanoma or history Hybrid,

A process to ollow up with patients Append modifer to CPTo melanoma. electronicwho either did not make an Category II codes: 7010F-3P.appointment within the specifed data collectionICD-9 diagnosis codes: 172.0, 172.1, 172.2,timerame or who missed a supplemented172.3, 172.4, 172.5, 172.6, 172.7, 172.8,scheduled appointment. with medical172.9, V10.82

recordNumerator Details AND abstractionPatient inormation entered into arecall system that includes target date CPT E/M codes: 99201, 99202, 99203,or the next exam specifed AND a 99204, 99205, 99212, 99213, 99214,process to ollow up with patients 99215, 99241, 99242, 99243, 99244,regarding missed or unscheduled 99245appointments (7010F)

*To satisy this measure, the recallsystem must be linked to a processto notiy patients when their nextphysical exam is due and to ollow up

with patients who either did not makean appointment within the specifedtimerame or who missed a scheduledappointment and must include theollowing elements at a minimum: pa-tient identifer, patient contact inorma-tion, cancer diagnosis(es), dates(s) oinitial cancer diagnosis (i known), andthe target date or the next completephysical exam.

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3-Item CareMeasure ID #: Care The 15-item and the 3-item CTM The CTM has application to all hospitalized Standardized

Transition 0228 Transitions share the same set o response adults. Testing has not included children, patient surveyMeasure Program patterns: Strongly Disagree; Disagree; but the measure may have potential(CTM-3)1 Agree; Strongly Agree (there is also application to this population as well.

a response or Dont Know; Dont Persons with cognitive impairment haveRemember; Not Applicable). Based on been included in prior testing, provided theya subjects response, a score can be are able to identiy a willing and able proxy.assigned to each item as ollows: The CTM has been tested in English- and

Spanish-speaking (using an available Strongly Disagree = 1Spanish version o the CTM) populations.

Disagree = 2

Agree = 3

Strongly Agree = 4

Next, the scores can be aggregatedacross either the 15 or 3 items, andthen transormed to a scale rangingrom 0 to 100. Thus the denominatoris 100 and the numerator can rangerom 0 to 100.

Recommended to survey within30 days o event.

1 NQF-endorsed measure, recommended or continued endorsement.

Documents

n Qf Care Coordination and Cr