informatics.gpcnetwork.org€¦ · Web view01/08/2017 · ['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','E10.39

Appendix C

eQCMs reuse for NEXT-D

Content PageIntroduction 1Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) 3Diabetes: Low Density Lipoprotein (LDL-C) Control (< 100 mg/dL) 6Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 10Hypertension: Improvement in Blood Pressure 17Diabetes: Foot Exam 26Diabetes: Medical Attention for Nephropathy 30Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 37Diabetes: Eye Exam 40Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)

45

Pneumococcal Vaccination Status for Older Adults 52

I. IntroductionClinical quality measures, also called CQMs, are tools that help us measure and monitor the quality of healthcare and the contribution of those healthcare services towards improved health outcomes. Some of these measures may be helpful additions to our project assessing changes in diabetes care after the ACA.

We are only asking for these measures from sites that are already calculating them. For sites not calculating some or all of these measures as part of ongoing quality assessment, we will instead use the diagnosis and procedure codes, labs, vitals, and medications you are delivering to us to assess outcomes after the ACA.

For sites that are already calculating these eQCM, we will ask you to report your numerator and denominator for these eQCM measures.All eCQMs listed here are collected from the 2017 performance period. If you are interested in a complete list of measures they can be found at https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms?field_year_value=2&keys=

Meaning of the technical terms used in all measurements:Initial patient population (IPP) – The group of patients (or events/episodes of care) that the measure is designed to address.Denominator – Is a subset of the IPP for which the measure applies (may also be the same as the IPP).

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https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms?field_year_value=2&keys

https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms?field_year_value=2&keys

Numerator – Is a subset of the denominator and refers to the patients who meet the measure specified clinical requirements or the events/episodes of care from the denominator where the measure specific requirements have been performed.Denominator Exclusions – Is a subset of the denominator. Exclusion specifications remove patients/events from the denominator who meet specific criteria that make it clinically unnecessary for the patient to receive the numerator clinical action.Denominator Exception – Is a subset of the denominator. Exception specifications remove patients/events from the denominator only if the numerator criteria are not met. Exceptions are generally provider or patient determined reasons for refusing certain clinical actions.Measurement period– This is also known as the EHR reporting period and refers to the time frame for which the CQMs will be calculated. For more information on determining your CQM reporting period, refer to the reporting requirements at the end of this guide.

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I. Detailed description of elements

1. Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS122v5_2.htmleMeasure Title Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)

eMeasure Identifier (Measure Authoring Tool)

122 eMeasure Version number 5.0.000

NQF Number 0059 GUID f2986519-5a4e-4149-a8f2-af0a1dc7f6bc

Measurement Period January 1, 20XX through December 31, 20XX

Measure Steward National Committee for Quality Assurance

Measure Developer National Committee for Quality Assurance

Endorsed By National Quality Forum

Description Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

Copyright Physician Performance Measure (Measures) and related data specifications were developed by the National Committee for Quality Assurance (NCQA).

The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures.

(C) 2008-2016 National Committee for Quality Assurance. All Rights Reserved.

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2015 American Medical Association. LOINC(R) copyright 2004-2015 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2015 International Health Terminology Standards Development Organisation. ICD-10 copyright 2015 World Health Organization. All Rights Reserved.

Disclaimer These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Measure Scoring Proportion

Measure Type Outcome

Stratification None

Risk Adjustment None

Rate Aggregation None

Rationale As the seventh leading cause of death in the U.S., diabetes kills approximately 75,000 people a year (CDC FastStats 2015). Diabetes is a group of diseases marked by high blood glucose levels, resulting from the body's inability to produce or use insulin (CDC Statistics 2014, ADA Basics 2013). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and premature death. (CDC Fact Sheet 2014).

In 2012, diabetes cost the U.S. an estimated $245 billion: $176 billion in direct medical costs and $69 billion in reduced productivity. This is a 41 percent increase from the estimated $174 billion spent on diabetes in 2007 (ADA Economic 2013).

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https://ecqi.healthit.gov/system/files/ecqm/measures/CMS122v5_2.html

Reducing A1c blood level results by 1 percentage point (eg, from 8.0 percent to 7.0 percent) helps reduce the risk of microvascular complications (eye, kidney and nerve diseases) by as much as 40 percent (CDC Estimates 2011).

Clinical Recommendation Statement

American Diabetes Association (2015):

- Lowering A1C to approximately 7% or less has been shown to reduce microvascular complications of diabetes, and, if implemented soon after the diagnosis of diabetes, it is associated with long-term reduction in macrovascular disease. Therefore, a reasonable A1C goal for many nonpregnant adults is 7%. (Level of evidence: B)

- Providers might reasonably suggest more stringent A1C goals (such as 6.5%) for selected individual patients if this can be achieved without significant hypoglycemia or other adverse effects of treatment. Appropriate patients might include those with short duration of diabetes, type 2 diabetes treated with lifestyle or metformin only, long life expectancy, or no significant cardiovascular disease (CVD). (Level of evidence: C)

- Less stringent A1C goals (such as 8%) may be appropriate for patientswith a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbidconditions, or long-standing diabetes in whom the general goal is difficult to attain despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin. (Level of evidence: B)

Improvement Notation Lower score indicates better quality

Reference American Diabetes Association. Glycemic targets. Sec. 6. In Standards of Medical Care in Diabetesd2015. Diabetes Care 2015;38(Suppl. 1):S33-S40

Reference American Diabetes Association. 2013. Diabetes Basics. www.diabetes.org/diabetes-basics/?loc=GlobalNavDB

Reference American Diabetes Association (ADA). April 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. Vol. 36 no. 41033-46. http://care.diabetesjournals.org/content/36/4/1033.full

Reference Centers for Disease Control and Prevention (CDC). 2014. National Diabetes Statistics Report. http://www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the-united-states.pdf

Reference Centers for Disease Control and Prevention (CDC). 2015. FastStats: Deaths and Mortality. www.cdc.gov/nchs/fastats/deaths.htm.

Reference Centers for Disease Control and Prevention. 2011. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf

Reference Centers for Disease Control and Prevention. 2014. CDC Features. Diabetes Latest. www.cdc.gov/features/diabetesfactsheet/.

Definition None

Guidance Patient is numerator compliant if most recent HbA1c level >9%, the most recent HbA1c result is missing, or if there are no HbA1c tests performed and results documented during the measurement period. If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance.

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.

Transmission Format TBD

Initial Population Patients 18-75 years of age with diabetes with a visit during the measurement period

Denominator Equals Initial Population

Denominator Exclusions

None

Numerator Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%

Numerator Exclusions Not Applicable

Denominator Exceptions

None

Supplemental Data Elements

For every patient evaluated by this measure also identify payer, race, ethnicity and sex

Population Criteria Initial Population =

o AND: "Diagnosis: Diabetes" overlaps "Measurement Period"o AND: Age>= 18 year(s) at: "Measurement Period"

4

o AND: Age< 75 year(s) at: "Measurement Period"o AND: Union of:

"Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"

Denominator =o AND: Initial Population

Denominator Exclusions =o None

Numerator =o 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 =

o None Denominator Exceptions =

o None Stratification =

o NoneData Criteria (QDM Variables)

NoneTable 1. Data elements from CMS122v5

Data element CodeDiagnosis: Diabetes 'SNOMED-CT':

['190330002','190331003','190368000','190369008','190372001','190389009','190390000','199223000','199225007','199226008','199227004','199228009','199229001','199230006','23045005','237599002','237618001','237627000','28032008','313435000','313436004','314771006','314772004','314893005','314902007','314903002','314904008','359642000','44054006','46635009','4783006','75682002','76751001','81531005','9859006'],'ICD-9-CM':['250.00','250.01','250.02','250.03','250.10','250.11','250.12','250.13','250.20','250.21','250.22','250.23','250.30','250.31','250.32','250.33','250.40','250.41','250.42','250.43','250.50','250.51','250.52','250.53','250.60','250.61','250.62','250.63','250.70','250.71','250.72','250.73','250.80','250.81','250.82','250.83','250.90','250.91','250.92','250.93','357.2','362.01','362.02','362.03','362.04','362.05','362.06','362.07','366.41','648.00','648.01','648.02','648.03','648.04'],'ICD-10-CM':['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','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','E11.329','E11.331','E11.339','E11.341','E11.349','E11.351','E11.359','E11.36','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','E13.329','E13.331','E13.339','E13.341','E13.349','E13.351','E13.359','E13.36','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','O2

5

4.811','O24.812','O24.813','O24.819','O24.82','O24.83']},'Encounter, Performed: Annual Wellness Visit

'HCPCS':['G0438','G0439']

Encounter, Performed: Face-to-Face Interaction

'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']

Encounter, Performed: Home Healthcare Services

'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']

Encounter, Performed: Office Visit

'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']

Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up

'CPT':['99395','99396','99397']

Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up

'CPT':['99385','99386','99387']

Laboratory Test, Performed: HbA1c Laboratory Test

'LOINC':['17856-6','4548-4','4549-2']

Patient Characteristic Ethnicity: Ethnicity

'CDC Race':['2135-2','2186-5']

Patient Characteristic Payer: Payer

'Source of Payment Typology':['1','11','111','112','113','119','12','121','122','123','129','19','2','21','211','212','213','219','22','23','24','25','29','3','31','311','3111','3112','3113','3114','3115','3116','3119','312','3121','3122','3123','313','32','321','3211','3212','32121','32122','32123','32124','32125','32126','322','3221','3222','3223','3229','33','331','332','333','334','34','341','342','343','349','35','36','361','362','369','37','371','3711','3712','3713','372','379','38','381','3811','3812','3813','3819','382','389','39','4','41','42','43','44','5','51','511','512','513','514','515','519','52','521','522','523','529','53','54','55','59','6','61','611','612','613','619','62','63','64','69','7','71','72','73','79','8','81','82','821','822','823','83','84','85','89','9','91','92','93','94','95','951','953','954','959','96','98','99','9999']},

Patient Characteristic Race: Race

'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']

Patient Characteristic Sex: ONC Administrative Sex

'AdministrativeGender':['F','M']

2.Low Density Lipoprotein (LDL-C) Control (< 100 mg/dL)

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS163v5_2.htmleMeasure Title Diabetes: Low Density Lipoprotein (LDL-C) Control (< 100 mg/dL)



NQF Number Not Applicable GUID 0dac1dec-e011-493b-a281-7c28964872dd




Endorsed By None

Description Percentage of patients 18-75 years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dL) during the measurement period.


The Measures are copyrighted but can be reproduced and distributed, without modification, for noncommercial

6


purposes (eg, use by healthcare providers in connection with their practices). Commercial use is defined as the sale, licensing, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial use of the Measures requires a license agreement between the user and NCQA. NCQA is not responsible for any use of the Measures.









Stratification None



Rationale Diabetes mellitus (diabetes) is a group of diseases characterized by high blood glucose levels caused by the body's inability to correctly produce or utilize the hormone insulin. It is recognized as a leading cause of death and disability in the U.S. and is highly underreported as a cause of death. Diabetes may cause life-threatening, life-ending or life-altering complications, including poor cholesterol, specifically lipoprotein (LDL). Clinical guidelines recommend lifestyle modifications that include reducing intake of saturated fat, trans fat and cholesterol; weight loss; and increased physical activity (American Diabetes Association 2009). Statin therapy is suggested for eligible patients whose levels are consistently and significantly higher (American Diabetes Association 2009).


American Diabetes Association (2009): In most adult patients, measure fasting lipid profile at least annually. In adults with low-risk lipid values (LDL cholesterol < 100 mg/dl, HDL cholesterol > 50 mg/dl, and triglycerides < 150 mg/dl), lipid assessments may be repeated every 2 years. American Association of Clinical Endocrinologists (2007): Aggressive management of dyslipidemia in patients with diabetes mellitus is critical; treat patients to achieve the following goal: LDL-C < 100 mg/dL (< 70 mg/dL is recommended for patients with diabetes mellitus and coronary artery disease).

Improvement Notation Higher score indicates better quality

Reference American Diabetes Association. 2009. "Standards of Medical Care in Diabetes-2009." Diabetes Care 2009 32 (Suppl 1):S6-S12.

Reference American Association of Clinical Endocrinologists. 2007. "Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus." Endocr Pract 13(Suppl 1):4-68.

Definition None

Guidance The patient is not numerator compliant if the result for the most recent LDL-C test during the measurement period is >= 100 mg/dL, or is missing, or if an LDL-C test was not performed during the measurement period.

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.





None

7

Numerator Patients whose most recent LDL-C level performed during the measurement period is <100 mg/dL



None




o AND: "Diagnosis: Diabetes" overlaps "Measurement Period"o AND: Age >= 18 year(s) at: "Measurement Period"o AND: Age < 75 year(s) at: "Measurement Period"o AND: Union of:




Numerator =o AND: "Laboratory Test, Performed: LDL-c" satisfies all:

Most Recent: (result) during "Measurement Period" (result < 100 mg/dL)

Numerator Exclusions =o None

Denominator Exceptions =o None

Stratification =o None

Data Criteria (QDM Variables) None

Table 2. Data elements from CMS163v5 Data element CodesDiagnosis: Diabetes 'SNOMED-CT':

['190330002','190331003','190368000','190369008','190372001','190389009','190390000','199223000','199225007','199226008','199227004','199228009','199229001','199230006','23045005','237599002','237618001','237627000','28032008','313435000','313436004','314771006','314772004','314893005','314902007','314903002','314904008','359642000','44054006','46635009','4783006','75682002','76751001','81531005','9859006'],'ICD-9-CM':['250.00','250.01','250.02','250.03','250.10','250.11','250.12','250.13','250.20','250.21','250.22','250.23','250.30','250.31','250.32','250.33','250.40','250.41','250.42','250.43','250.50','250.51','250.52','250.53','250.60','250.61','250.62','250.63','250.70','250.71','250.72','250.73','250.80','250.81','250.82','250.83','250.90','250.91','250.92','250.93','357.2','362.01','362.02','362.03','362.04','362.05','362.06','362.07','366.41','648.00','648.01','648.02','648.03','648.04'],'ICD-10-CM':['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','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','E11.329','E11.331','E11.339','E11.341','E11.349','E11.351','E11.359','E11.36','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','E1

8

1.65','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','E13.329','E13.331','E13.339','E13.341','E13.349','E13.351','E13.359','E13.36','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']

Encounter, Performed: Annual Wellness Visit

'HCPCS':['G0438','G0439']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']


'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']


'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']


'CPT':['99395','99396','99397']


'CPT':['99385','99386','99387']

Laboratory Test, Performed: LDL-c

'LOINC':['13457-7','18261-8','18262-6','2089-1','49132-4','55440-2']


'CDC Race':['2135-2','2186-5']


'Source of Payment Typology':['1','11','111','112','113','119','12','121','122','123','129','19','2','21','211','212','213','219','22','23','24','25','29','3','31','311','3111','3112','3113','3114','3115','3116','3119','312','3121','3122','3123','313','32','321','3211','3212','32121','32122','32123','32124','32125','32126','322','3221','3222','3223','3229','33','331','332','333','334','34','341','342','343','349','35','36','361','362','369','37','371','3711','3712','3713','372','379','38','381','3811','3812','3813','3819','382','389','39','4','41','42','43','44','5','51','511','512','513','514','515','519','52','521','522','523','529','53','54','55','59','6','61','611','612','613','619','62','63','64','69','7','71','72','73','79','8','81','82','821','822','823','83','84','85','89','9','91','92','93','94','95','951','953','954','959','96','98','99','9999']


'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']



3. Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS22v5_2.htmleMeasure Title Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented



NQF Number Not Applicable GUID 9a033a94-3d9b-11e1-8634-00237d5bf174


9


Measure Steward Centers for Medicare & Medicaid Services (CMS)

Measure Developer Quality Insights of Pennsylvania

Endorsed By None

Description Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

Copyright Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Quality Insights of Pennsylvania disclaims all liability for use or accuracy of any Current Procedural Terminology (CPT [R]) or other coding contained in the specifications.

CPT (R) contained in the Measure specifications is copyright 2007- 2016 American Medical Association.

LOINC (R) copyright 2004-2015 [2.54] Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms (R) (SNOMED CT [R]) copyright 2004-2015 [2015-09] International Health Terminology Standards Development Organization. All Rights Reserved.


Disclaimer These performance measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.



Measure Type Process

Stratification None



Rationale Hypertension is a prevalent condition that affects approximately 66.9 million people in the United States. It is estimated that about 20-40% of the adult population has hypertension; the majority of people over age 65 have a hypertension diagnosis (Appleton SL, et. al., 2012 and Luehr D, et. al., 2012). Winter (2013) noted that 1 in 3 American adults have hypertension and the lifetime risk of developing hypertension is 90% (Winter KH, et. al., 2013). The African American population or non-Hispanic Blacks, the elderly, diabetics and those with chronic kidney disease are at increased risk of stroke, myocardial infarction and renal disease. Non-Hispanic Blacks have the highest prevalence at 38.6% (Winter KH, et. al., 2013). Hypertension is a major risk factor for ischemic heart disease, left ventricular hypertrophy, renal failure, stroke and dementia (Luehr D, et. al., 2012).

Hypertension is the most common reason for adult office visits other than pregnancy. Garrison (2013) stated that in 2007, 42 million ambulatory visits were attributed to hypertension (Garrison GM and Oberhelman S, 2013). It also has the highest utilization of prescription drugs. Numerous resources and treatment options are available, yet only about 40-50% of the hypertensive patients have their blood pressure under control (<140/90) (Appleton SL, et. al., 2012, Luehr D, et. al., 2012). In addition to medication non-compliance, poor outcomes are also attributed to poor adherence to lifestyle changes such as a low-sodium diet, weight loss, increased exercise and limiting alcohol intake. Many adults find it difficult to continue medications and lifestyle changes when they are asymptomatic. Symptoms of elevated blood pressure usually do not occur until secondary problems arise such as with vascular diseases (myocardial infarction, stroke, heart failure and renal insufficiency) (Luehr D, et. al., 2012).

Appropriate follow-up after blood pressure measurement is a pivotal component in preventing the progression of hypertension and the development of heart disease. Detection of marginally or fully elevated blood pressure by a specialty clinician warrants referral to a provider familiar with the management of hypertension and prehypertension. The 2010 ACCF/AHA Guideline for the Assessment of Cardiovascular Risk in Asymptomatic Adults continues to support using a global risk score such as the Framingham Risk Score, to assess risk of coronary heart disease (CHD) in all asymptomatic adults (Greenland P, et. al., 2010). Lifestyle modifications have demonstrated effectiveness in lowering blood pressure (JNC 7, 2003). The synergistic effect of several lifestyle modifications results in greater benefits than a single modification alone. Baseline diagnostic/laboratory testing establishes if a co-existing underlying condition is the etiology of hypertension and evaluates if end organ damage from hypertension has already occurred. Landmark trials such as ALLHAT have repeatedly proven the efficacy of pharmacologic therapy to control blood pressure and reduce the complications of hypertension. Follow-up intervals based on blood pressure control have been established by the JNC 7 and the USPSTF.

Clinical The U.S. Preventive Services Task Force (USPSTF) recommends screening for high blood pressure in adults age 18

10

Recommendation Statement

years and older. This is a grade A recommendation.


Reference U.S. Preventive Services Task Force (USPSTF) (2007). Screening for high blood pressure: U.S. Preventive Services Task Force reaffirmation recommendation statement. Annals of Internal Medicine; 147(11):783-6

Reference U.S. Department of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute & National High Blood Pressure Education Program (2003). The Seventh Report of the Joint National Committee on the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7). NIH Publication No. 03-5233

Reference Garrison GM & Oberhelman S (2013). Screening for hypertension annually compared with current practice. Annals of Family Medicine, 11 (2), 116-121.

Reference Luehr D, Woolley T, Burke R, Dohmen F, Hayes R, Johnson M, Kerandi H, Margolis K, Marshall M, O'Connor P, Pereira C, Reddy G, Schlichte A & Schoenleber M (2012). Hypertension diagnosis and treatment; Institute for Clinical Systems Improvement health care guideline. Updated November, 2012.

Reference Appleton SL, Neo C, Hill C L, Douglas K A & Adams R J (2012). Untreated hypertension: prevalence and patient factors and beliefs associated with under-treatment in a population sample. Journal of Human Hypertension, advance online publication December 13, 2012.

Reference Winter K H, Tuttle L A & Viera A J (2013). Hypertension. Prim Care Clin Office Pract, 40, 179-194.

Definition Blood Pressure (BP) Classification: BP is defined by four (4) BP reading classifications: Normal, Pre-Hypertensive, First Hypertensive, and Second Hypertensive Readings

Recommended 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 below

Recommended 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) Consumption

Second 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 mmHg

Second Hypertensive Reading BP 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 recommend lifestyle modifications OR referral to Alternative/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 recommendations AND one or more of the Second Hypertensive Reading Interventions OR referral to Alternative/Primary Care Provider

Guidance Both the systolic and diastolic blood pressure measurements are required for inclusion. If there are multiple blood pressures on the same date of service, use the most recent as the representative blood pressure.

Eligible professionals who report the measure must perform the blood pressure screening at the time of a qualifying visit by an eligible professional and may not obtain measurements from external sources.

11

The intent of this measure is to screen patients for high blood pressure and provide recommended follow-up as indicated. The documented follow-up plan must be related to the current BP reading as indicated, example: "Patient referred to primary care provider for BP management."


Initial Population All patients aged 18 years and older before the start of the measurement period with at least one eligible encounter during the measurement period



Patient has an active diagnosis of hypertension

Numerator Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive



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

OR

Medical Reason(s):Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated.




o AND: Age>= 18 year(s) at: "Measurement Period"o AND: "Occurrence A of Encounter, Performed: BP Screening Encounter Codes" during "Measurement Period"


Denominator Exclusions =o OR: "Diagnosis: Diagnosis of hypertension" starts before start of "Occurrence A of Encounter, Performed: BP Screening

Encounter Codes" Numerator =

o 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)"

o 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:

12


(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"


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:

13


(result >= 140 mmHg) OR: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all:


(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"


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 =

o None Denominator Exceptions =

o OR: Union of: "Physical Exam, Performed not done: Medical or Other reason not done" for "Diastolic Blood Pressure" "Physical Exam, Performed not done: Patient Reason refused" for "Diastolic Blood Pressure" "Physical Exam, Performed not done: Medical or Other reason not done" for "Systolic Blood Pressure" "Physical Exam, Performed not done: Patient Reason refused" for "Systolic Blood Pressure" starts during "Occurrence A of Encounter, Performed: BP Screening Encounter Codes"

o OR: Union of: "Intervention, Order not done: Patient Reason refused" for "Referral to Alternative Provider / Primary Care Provider" "Intervention, Order not done: Patient Reason refused" for "Lifestyle Recommendation" "Intervention, Order not done: Patient Reason refused" for "Weight Reduction Recommended" "Intervention, Order not done: Patient Reason refused" for "Dietary Recommendations" "Intervention, Order not done: Patient Reason refused" for "Physical Activity Recommendation" "Intervention, Order not done: Patient Reason refused" for "Moderation of ETOH Consumption Recommendation" "Medication, Order not done: Patient Reason refused" for "Anti-Hypertensive Pharmacologic Therapy" "Laboratory Test, Order not done: Patient Reason refused" for "Laboratory Tests for Hypertension" "Diagnostic Study, Order not done: Patient Reason refused" for "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" Stratification =

o None

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"

Table 3a. Data elements used in CMS22v5.Data Element CodesDiagnosis: Diagnosis of hypertension

SNOMED-CT:['102932008','10725009','10964002','1201005','123799005','123800009','14973001','170577003','170578008','170579000','170586008','185264001','185716009','185717000','194783001','194785008','194788005','194791005','19769006','23130000','233815004','233941006','233942004','233943009','233944003','233945002','233946001','234072000','234073005','234075003','237279007','270440008','28119000','288250001','31992008','34742003','371125006','371622005','38341003','39018007','395050009','397748008','398254007','401117004','402832006','4210003','423674003','428575007','429198000','429457004','44772007','46481004','46764007','48146000','48194001','52698002','56218007','57684003','59621000','59720008','59997006','65518004','68267002','70272006','7341000

14

7','74451002','78975002','81626002','84094009','8762007','89242004'],ICD-9-CM:['401.1','401.9','402.01','402.11','402.91','403.01','403.11','403.91','404.01','404.02','404.03','404.11','404.12','404.13','404.91','404.92','404.93','405.01','405.11','405.19','405.91','405.99'],ICD-10-CM:['H35.039','I10','I11.0','I11.9','I12.0','I12.9','I13.0','I13.10','I13.11','I13.2','I15.0','I67.4']

Diagnostic Study, Order: ECG 12 lead or study order

LOINC':['11524-6','34534-8']

Diagnostic Study, Order not done: Patient Reason refused

SNOMED-CT:['105480006','183944003','183945002','413310006','413311005','413312003']

Encounter, Performed: BP Screening Encounter Codes

'SNOMED-CT':['103705002','108220007','108221006','108224003','12843005','13607009','14736009','18170008','185349003','185463005','185465003','207195004','209099002','210098006','270427003','270430005','30346009','306677009','308335008','35025007','37894004','390906007','406547006','439708006','4525004','46662001','50357006','76464004','78318003','83607001','86013001','90526000'],'CPT':['90791','90792','90832','90834','90837','90839','90845','90880','92002','92004','92012','92014','96118','99201','99202','99203','99204','99205','99212','99213','99214','99215','99281','99282','99283','99284','99285','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','99385','99386','99387','99395','99396','99397'],'CDT':['D7140','D7210'],'HCPCS':['G0101','G0402','G0438','G0439']

Intervention, Order: Dietary Recommendations

'SNOMED-CT':['103699006','11816003','182922004','182954008','182955009','182956005','182960008','183061003','183065007','183070000','183071001','281085002','284071006','284352003','304491008','306163007','361231003','370847001','386464006','410114009','410171007','410177006','410270001','413315001','418995006','424753004','443288003','61310001']'HCPCS':['S9452','S9470'],'ICD-9-CM':['V65.3'],'ICD-10-CM':['Z71.3']

Intervention, Order: Followup within 4 weeks

'SNOMED-CT':['183617005','183618000','183619008','183620002','183621003','183622005','183623000']

Intervention, Order: Followup within one year

'SNOMED-CT':['183617005','183618000','183619008','183620002','183621003','183622005','183623000','183624006','183625007','183626008','183627004','183628009','300042001']

Intervention, Order: Lifestyle Recommendation

'SNOMED-CT':['313204009','39155009','443402002']

Intervention, Order: Moderation of ETOH Consumption Recommendation

'SNOMED-CT':['24165007','38670004','390857005','408947007','413473000','417096006','431260004']

Intervention, Order: Physical Activity Recommendation

'SNOMED-CT':['281090004','304507003','304549008','386291006','386292004','386373004','386463000','410289001'],'HCPCS':['S9451'],'ICD-9-CM':['V65.41']

Intervention, Order: Referral to Alternative Provider / Primary Care Provider

'SNOMED-CT':['134403003','183516009','183561008','183856001','306206005','306253008','308470006']

Intervention, Order: Weight Reduction Recommended

'SNOMED-CT':['170795002','266724001','268523001','408289007','410200000'],'HCPCS':['S9449']

Intervention, Order not done: Patient Reason refused

'SNOMED-CT':['105480006','183944003','183945002','413310006','413311005','413312003']

15

Laboratory Test, Order: Laboratory Tests for Hypertension

'LOINC': ['24321-2','24323-8','24356-8','24357-6','24362-6','2888-6','57021-8','57782-5','58410-2']

Laboratory Test, Order not done: Patient Reason refused

'SNOMED-CT':['105480006','183944003','183945002','413310006','413311005','413312003']

Medication, Order: Anti-Hypertensive Pharmacologic Therapy

'RxNorm':['1000001','1009220','1009247','1009315','1009320','1011710','1011713','1011718','1011729','1011736','1011739','1011750','1011753','1013930','1013937','104222','104308','1050798','1050803','1050806','1050809','1050812','1087322','1091646','1091652','1092566','1100691','1191185','1233709','1234256','1235144','1235151','1297753','1297757','1299859','1299871','1299890','1299896','1299897','152916','153822','153823','1665057','1719286','1719290','197361','197379','197380','197381','197382','197383','197417','197418','197419','197436','197437','197438','197439','197475','197476','197497','197498','197499','197500','197625','197626','197627','197628','197730','197731','197732','197745','197746','197770','197788','197815','197816','197848','197849','197884','197885','197886','197887','197951','197954','197960','197963','197977','197978','197979','197986','197987','198000','198001','198005','198006','198007','198008','198032','198033','198034','198035','198036','198037','198104','198105','198110','198111','198112','198141','198188','198189','198222','198223','198224','198225','198284','198285','198286','198312','198313','198314','198316','198319','198369','198370','198371','198372','199277','199329','199351','199352','199353','199491','199610','199622','199717','199757','199776','199782','199783','199816','199817','199850','199903','199919','200031','200032','200033','200094','200095','200096','200284','200285','205304','205305','205326','205364','245283','245284','245854','245855','247516','249851','251856','251857','260376','261962','282486','282755','283316','283317','308135','308136','308614','308700','308701','308962','308963','308964','309198','310139','310140','310429','310664','310792','310793','310796','310797','310798','310809','310811','310812','310818','311353','311354','311671','311983','311984','311985','312481','312482','312483','312593','312594','312748','312749','312750','313096','313215','313217','313219','313988','314029','314076','314077','314132','314203','317173','349199','349200','349201','349353','349373','349401','349405','349483','351292','351293','360344','387013','391980','401965','401968','402695','402696','402698','403853','403854','403855','404011','404013','411434','429503','477130','484152','485471','562518','562520','577776','578325','578330','597967','597971','597974','597977','597980','597984','597987','597990','597993','636042','636045','636360','636361','639537','686924','722126','722131','722134','722137','727574','727575','730861','730866','730869','730872','751612','751618','763519','763574','763589','790489','802749','830795','830801','830837','830845','830861','830865','830869','830872','830874','830877','830879','830882','830897','830900','831054','831102','831103','831359','833199','833217','833222','833237','845488','848131','848135','848140','848145','848151','854901','854905','854908','854916','854919','854925','854984','854988','856422','856429','856448','856457','856460','856481','856519','856535','856556','856569','856578','856713','856724','856733','857166','857169','857174','857183','857187','858580','858587','858593','858599','858603','858607','858613','858616','858618','858621','858804','858810','858813','858817','858821','858824','858828','858921','860510','860516','860522','860532','861402','862006','862013','862019','862025','866412','866419','866427','866436','866452','866461','866472','866479','866482','866491','866508','866511','866514','866924','876514','876519','876524','876529','884173','884185','884189','884192','884198','884203','884221','884225','885878','885880','885882','892791','896758','896762','896766','896771','896976','896983','896987','897584','897590','897596','897612','897618','897624','897630','897635','897640','897646','897649','897666','897683','897719','897722','897781','897783','897844','897853','898316','898342','898346','898350','898353','898356','898359','898362','898367','898372','898378','898687','898690','898719','898723','901438','904561','904567','904579','904589','904601','904622','904630','905199','905222','905225','905353','905377','905395','966571','977865','977880','977883','977959','978577','978581','979432','979436','979464','979468','979471','979480','979485','979492','998675','998679','998685','998689','998693','998694','998695','999967','999986','999991','999996']

Medication, Order not done: Patient Reason refused

'SNOMED-CT':['105480006','183944003','183945002','413310006','413311005','413312003']

16

Physical Exam, Performed: Diastolic Blood Pressure

'LOINC':['8462-4']

Physical Exam, Performed: Systolic Blood Pressure

LOINC':['8480-6']

Physical Exam, Performed not done: Medical or Other reason not done

SNOMED-CT':['183932001','397745006','407563006','428119001']

Physical Exam, Performed not done: Patient Reason refused

SNOMED-CT':['105480006','183944003','183945002','413310006','413311005','413312003']

Reason: Finding of Hypertension

SNOMED-CT':['198941007','31992008','38341003','443482000','48146000','48194001','56218007','62275004']


'CDC Race':['2135-2','2186-5']




'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']



4. Hypertension: Improvement in Blood Pressure

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS65v6_2.htmleMeasure Title Hypertension: Improvement in Blood Pressure



NQF Number Not Applicable GUID 1d8363ce-a529-490b-8c98-9b54aa75da06


Measure Steward Centers for Medicare & Medicaid Services (CMS)


Endorsed By None

Description Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Copyright Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications.




17





Stratification None



Rationale Hypertension, or high blood pressure, is a very common and dangerous condition that increases risk for heart disease and stroke, two of the leading causes of death for Americans (Farley et al., 2010). Compared with other dietary, lifestyle, and metabolic risk factors, high blood pressure is the leading cause of death in women and the second-leading cause of death in men, behind smoking (Danaei et al., 2011). Approximately 1 in 3 U.S. adults, or about 70 million people, have high blood pressure but only about half (52%) of these people have their high blood pressure under control. Additionally, data from NHANES 2011 to 2012 found that 17.2% of U.S. adults are not aware they have hypertension (Nwankwo et al., 2013). Projections show that by 2030, approximately 41.4% of US adults will have hypertension, an increase of 8.4% from 2012 estimates (Heidenreich et al., 2011).

The estimated direct and indirect cost of high blood pressure for 2011 is $46.4 billion. This total includes direct costs such as the cost of physicians and other health professionals, hospital services, prescribed medications and home health care, as well as indirect costs due to loss of productivity from premature mortality (Mozaffarian et al., 2015). Projections show that by 2030, the total cost of high blood pressure could increase to an estimated $274 billion (Heidenreich et al., 2011).

Better control of blood pressure has been shown to significantly reduce the probability that undesirable and costly outcomes will occur. In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence (35-40%), myocardial infarction (20-25%) and heart failure (>50%) (Chobanian et al., 2003). Thus, the relationship between the measure (control of hypertension) and the long-term clinical outcomes listed is well established.


The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7): Treating systolic blood pressure and diastolic blood pressure to targets that are <140/90 mmHg is associated with a decrease in cardiovascular disease complications

Improvement Notation A higher score indicates better quality

Reference Centers for Disease Control and Prevention (CDC). Prevalence of self-reported cardiovascular disease among persons aged >=35 years with diabetes: United States, 1997-2005. MMWR Morb Mortal Wkly Rep. 2007;56:1129-1132.

Reference Chobanian AV, Bakris GL, Black HR, et al; National Heart, Lung, and Blood Institute Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; National High Blood Pressure Education Program Coordinating Committee. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BloodPressure: the JNC 7 report. JAMA. 2003;289(19):2560-2572.

Reference Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ, Ezzati M. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors [published correction appears in PLoS Med. 2011;8. doi: 10.1371/annotation/0ef47acd-9dcc-4296-a897-872d182cde57]. PLoS Med. 2009;6:e1000058.

Reference Farley TA, Dalal MA, Mostashari F, Frieden TR. Deaths preventable in the US by improvements in the use of clinical preventive services. Am J Prev Med. 2010;38:600-9.

Reference Heidenreich, P.A., J.G. Trogdon, O.A. Khavjou, et al. 2011. "Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association." Circulation.123:933-944.

Reference Mozaffarian, D., E.J. Benjamin, A.S. Go, et al. 2015. "Heart disease and stroke statistics-2015 update: a report from the American Heart Association." Circulation. 131:e29-e322. doi: 10.1161/CIR.0000000000000152

Reference Nwankwo T, Yoon SS, Burt V, Gu Q. Hypertension among adults in the US: National Health and Nutrition Examination Survey, 2011-2012. NCHS Data Brief, No. 133. Hyattsville, MD: National Center for Health Statistics, Centers for Disease Control and Prevention, US Dept of Health and Human Services, 2013.

Reference Prevention, Detection, Evaluation, and Treatment of High Blood Pressure - The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. NIH Publication No.03 - 5233 December 2003

Definition Adequate control: a systolic blood pressure < 140 mmHg.

18

Uncontrolled blood pressure: a systolic blood pressure >= 140 mmHg.

Uncontrolled baseline blood pressure: systolic blood pressure >= 140 mmHg that is taken during the first outpatient encounter of the measurement year in which the patient has an active diagnosis of hypertension. This must occur during the first six months of the year. If the patient with hypertension has uncontrolled blood pressure during the first outpatient encounter of the measurement year, then include the patient in the initial patient population of the measure.

Follow-up blood pressure: systolic blood pressure taken during the first outpatient encounter during the measurement year that occurs at least six months after the baseline blood pressure.

Improvement in blood pressure: the follow-up blood pressure is at least 10 mmHg less than the baseline systolic blood pressure.

Guidance Blood pressure readings must be taken while the patient is sitting. If multiple measurements occur on the same date, the last systolic and diastolic readings should be used.

"Occurrence A of Physical Exam, Performed: Systolic Blood Pressure (result)" represents the baseline blood pressure, which must occur prior to "Occurrence B of Physical Exam, Performed: Systolic Blood Pressure (result)", which represents the follow-up blood pressure.

To calculate the "Physical Exam, Performed: Delta systolic blood pressure (result)" data element, subtract the value of "Occurrence B of Physical Exam, Performed: Systolic Blood Pressure (result)" from the value of "Occurrence A of Physical Exam, Performed: Systolic Blood Pressure (result)".

The data element "Physical Exam, Performed: Delta systolic blood pressure (result)" is intended to represent the result of the mathematic comparison between systolic blood pressures taken during two separate visits. This is a calculation artifact, and there's no requirement to document the delta data element in the medical record.


Initial Population All patients aged 18-85 years of age, who had at least one outpatient visit in the first six months of the measurement year, who have a diagnosis of essential hypertension documented during that outpatient visit, and who have uncontrolled baseline blood pressure at the time of that visit



Exclude from the denominator all patients with evidence of end-stage renal disease (ESRD) on or prior to December 31 of the measurement year. Documentation of dialysis or kidney transplant also meets the criteria for evidence of ESRD.

Exclude from the denominator all patients with a diagnosis of pregnancy during the measurement year.

Numerator Patients whose follow-up blood pressure is at least 10 mmHg less than their baseline blood pressure or is adequately controlled.

If a follow-up blood pressure reading is not recorded during the measurement year, the patient's blood pressure is assumed "not improved."



None




o AND: Age>= 18 year(s) at: "Measurement Period"o AND: Age< 85 year(s) at: "Measurement Period"o AND: First:

"Occurrence A of Encounter, Performed: Blood Pressure Visit" satisfies all: < 6 month(s) starts after start of "Measurement Period" overlaps "Diagnosis: Essential Hypertension" overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)"

o AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all: Most Recent: (result) during "Occurrence A of Encounter, Performed: Blood Pressure Visit" (result >= 140 mmHg)


19

Denominator Exclusions =o OR: Union of:

"Procedure, Performed: Kidney Transplant" starts before end of "Measurement Period" "Procedure, Performed: Hemodialysis" starts before end of "Measurement Period" "Procedure, Performed: Peritoneal Dialysis" starts before end of "Measurement Period" "Diagnosis: Pregnancy" overlaps "Measurement Period" "Diagnosis: End Stage Renal Disease" overlaps "Measurement Period"

Numerator =o AND: "Occurrence B of Encounter, Performed: Blood Pressure Visit" satisfies all:

First: >= 6 month(s) starts after end of "Occurrence A of Encounter, Performed: Blood Pressure Visit" ends during "Measurement Period"

o AND: OR: "Physical Exam, Performed: Delta systolic blood pressure" satisfies all:

(result > 10 mmHg) starts after or concurrent with end of Most Recent: "Physical Exam, Performed: Systolic Blood Pressure (result)" during "Occurrence B of Encounter, Performed: Blood Pressure Visit"

overlaps "Occurrence B of Encounter, Performed: Blood Pressure Visit" OR: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all:

Most Recent: (result) during "Occurrence B of Encounter, Performed: Blood Pressure Visit" (result < 140 mmHg)





Table 3b. Data elements from CMS65v6.Data element CodesDiagnosis: End Stage Renal Disease

'SNOMED-CT':['236434000','236435004','236436003','46177005'],'ICD-9-CM':['585.6'],'ICD-10-CM':['N18.6']

Diagnosis: Essential Hypertension 'SNOMED-CT':['10725009','1201005','371125006','429457004','46481004','48146000','56218007','59621000','59720008','65518004','78975002'],'ICD-9-CM':['401.0','401.1','401.9'],'ICD-10-CM':['I10']

Diagnosis: Pregnancy 'SNOMED-CT':['102872000','102873005','102875003','14418008','169560008','169561007','169562000','169563005','169564004','169565003','169566002','169567006','169568001','199715003','237233002','237238006','237239003','237240001','237241002','237242009','237244005','248985009','281307002','314204000','41587001','45307008','47200007','57630001','58532003','59466002','65727000','72892002','77386006','83074005','9279009'],'ICD-9-CM':['633.11','633.21','633.81','633.91','640.01','640.03','640.83','641.03','641.13','641.21','641.23','641.31','641.33','641.81','641.83','641.91','641.93','642.01','642.02','642.03','642.11','642.12','642.13','642.21','642.22','642.23','642.31','642.32','642.33','642.62','642.63','642.71','642.72','642.73','642.91','642.92','642.93','643.01','643.03','643.81','643.91','643.93','644.03','644.13','644.21','645.11','645.13','645.21','645.23','646.01','646.03','646.11','646.12','646.13','646.21','646.22','646.23','646.31','646.33','646.41','646.42','646.43','646.51','646.52','646.53','646.61','646.62','646.63','646.71','646.73','646.81','646.82','646.83','646.91','646.93','647.01','647.02','647.03','647.11','647.12','647.13','647.21','647.22','647.23','647.31','647.32','647.33','647.41','647.42','647.43','647.51','647.52','647.53','647.61','647.62','647.63','647.81','647.82','647.83','647.91','647.92','647.93','648.01','648.02','648.03','648.11','648.12','648.13','648.21','648.22','648.23','648.31','648.32','648.33','648.41','648.42','648.43','648.51','648.52','648.53','648.61','648.62','648.63','648.71','648.72','648.73','648.81','648.82','648.83','648.91','648.92','648.93','649.01','649.02','649.03','649.11','649.12','649.13','649.21','649.22','649.23','649.31','649.32','649.33','649.41','649.42','649.43','649.51','649.53','649.61','649.62','649.63','649.71','649.73','651.01','651.03','651.11','651.13','651.21','651.23','651.31','651.33','651.41','651.43','651.51','6

20

51.53','651.61','651.63','651.71','651.73','651.81','651.83','651.91','651.93','652.01','652.03','652.11','652.13','652.21','652.23','652.31','652.33','652.41','652.43','652.51','652.53','652.61','652.63','652.71','652.73','652.81','652.83','652.91','652.93','653.01','653.03','653.11','653.13','653.21','653.23','653.31','653.33','653.41','653.43','653.51','653.53','653.61','653.63','653.71','653.73','653.81','653.83','653.91','653.93','654.01','654.02','654.03','654.11','654.12','654.13','654.21','654.23','654.31','654.32','654.33','654.41','654.42','654.43','654.51','654.52','654.53','654.61','654.62','654.63','654.71','654.72','654.73','654.81','654.82','654.83','654.91','654.92','654.93','655.01','655.03','655.11','655.13','655.21','655.23','655.31','655.33','655.41','655.43','655.51','655.53','655.61','655.63','655.71','655.73','655.81','655.83','655.91','655.93','656.01','656.03','656.11','656.13','656.21','656.23','656.31','656.33','656.41','656.43','656.51','656.53','656.61','656.73','656.81','656.83','656.91','656.93','657.01','657.03','658.01','658.03','658.11','658.13','658.21','658.23','658.31','658.33','658.41','658.43','658.81','658.83','658.91','658.93','659.01','659.03','659.11','659.13','659.21','659.23','659.31','659.33','659.41','659.43','659.51','659.53','659.61','659.63','659.71','659.73','659.81','659.83','659.91','659.93','660.01','660.03','660.11','660.13','660.21','660.23','660.31','660.33','660.41','660.43','660.51','660.53','660.61','660.63','660.71','660.73','660.81','660.83','660.91','660.93','661.01','661.03','661.11','661.13','661.21','661.23','661.31','661.33','661.41','661.43','661.91','661.93','662.01','662.03','662.11','662.13','662.21','662.23','662.31','662.33','663.01','663.03','663.11','663.13','663.21','663.23','663.31','663.33','663.41','663.43','663.51','663.61','663.63','663.81','663.83','663.91','663.93','664.01','664.11','664.21','664.31','664.51','664.61','664.81','664.91','665.01','665.03','665.11','665.31','665.41','665.51','665.61','665.71','665.72','665.81','665.83','665.91','665.92','665.93','666.02','666.12','666.22','666.32','667.02','667.12','668.01','668.02','668.03','668.11','668.12','668.13','668.21','668.22','668.23','668.81','668.82','668.83','668.91','668.92','668.93','669.01','669.02','669.03','669.11','669.12','669.13','669.51','669.61','669.71','669.81','669.82','669.83','669.91','669.92','669.93','670.02','671.01','671.02','671.03','671.11','671.12','671.13','671.21','671.22','671.23','671.31','671.33','671.42','671.51','671.52','671.53','671.81','671.82','671.83','671.91','671.92','671.93','672.02','673.01','673.02','673.03','673.11','673.12','673.13','673.21','673.22','673.23','673.31','673.32','673.33','673.81','673.82','674.01','674.02','674.03','674.12','674.22','674.32','674.42','674.51','674.52','674.53','674.82','674.92','675.01','675.02','675.03','675.11','675.12','675.13','675.21','675.22','675.23','675.81','675.82','675.83','675.91','675.92','675.93','676.01','676.02','676.03','676.11','676.12','676.13','676.21','676.22','676.23','676.31','676.32','676.41','676.42','676.43','676.51','676.52','676.53','676.61','676.62','676.63','676.81','676.82','676.83','676.91','676.92','676.93','678.01','678.03','678.11','678.13','679.01','679.02','679.03','679.11','679.12','679.13','V22.0','V22.1','V22.2','V23.0','V23.1','V23.2','V23.3','V23.41','V23.49','V23.5','V23.7','V23.81','V23.82','V23.83','V23.84','V23.85','V23.86','V23.89'],'ICD-10-CM':['O00.1','O00.2','O00.8','O00.9','O09.00','O09.01','O09.02','O09.03','O09.10','O09.11','O09.12','O09.13','O09.211','O09.212','O09.213','O09.219','O09.291','O09.292','O09.293','O09.299','O09.30','O09.31','O09.32','O09.33','O09.40','O09.41','O09.42','O09.43','O09.511','O09.512','O09.513','O09.519','O09.521','O09.522','O09.523','O09.529','O09.611','O09.612','O09.613','O09.619','O09.621','O09.622','O09.623','O09.629','O09.70','O09.71','O09.72','O09.73','O09.811','O09.812','O09.813','O09.819','O09.821','O09.822','O09.823','O09.829','O09.891','O09.892','O09.893','O09.899','O09.90','O09.91','O09.92','O09.93','O10.011','O10.012','O10.013','O10.019','O10.111','O10.112','O10.113','O10.119','O10.211','O10.212','O10.213','O10.219','O10.311','O10.312','O10.313','O10.319','O10.411','O10.412','O10.413','O10.419','O10.911','O10.912','O10.913','O10.919','O11.1','O11.2','O11.3','O11.9','O12.00','O12.01','O12.02','O12.03','O12.10','O12.11','O12.12','O12.13','O12.20','O12.21','O12.22','O12.23','O13.1','O13.2','O13.3','O13.9','O14.00','O14.02','O14.03','O14.10','O14.12','O14.13','O14.20','O14.22','O14.23','O14.90','O14.92','O14.93','O15.00','O15.02','O15.03','O16.1','O16.2','O16.3','O16.9','O20.0','O20.8','O20.9','O21.0','O21.1','O21.2','O21.8','O21.9','O22.00','O22.01','O22.02','O22.03','O22.10','O22.11','O22.12','O22.13','O22.20','O22.21','O22.22','O22.23','O22.30','O22.31','O22.32','O22.33','O22.40','O22.41','O22.42','O22.43','O22.50','O22.51','O22.52','O22.53','O22.8X1','O22.8X2','O22.8X3','O22.8X9','O22.90','O22.91','O22.92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21

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22

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23

O36.8223','O36.8224','O36.8225','O36.8229','O36.8230','O36.8231','O36.8232','O36.8233','O36.8234','O36.8235','O36.8239','O36.8290','O36.8291','O36.8292','O36.8293','O36.8294','O36.8295','O36.8299','O36.8910','O36.8911','O36.8912','O36.8913','O36.8914','O36.8915','O36.8919','O36.8920','O36.8921','O36.8922','O36.8923','O36.8924','O36.8925','O36.8929','O36.8930','O36.8931','O36.8932','O36.8933','O36.8934','O36.8935','O36.8939','O36.8990','O36.8991','O36.8992','O36.8993','O36.8994','O36.8995','O36.8999','O36.90X0','O36.90X1','O36.90X2','O36.90X3','O36.90X4','O36.90X5','O36.90X9','O36.91X0','O36.91X1','O36.91X2','O36.91X3','O36.91X4','O36.91X5','O36.91X9','O36.92X0','O36.92X1','O36.92X2','O36.92X3','O36.92X4','O36.92X5','O36.92X9','O36.93X0','O36.93X1','O36.93X2','O36.93X3','O36.93X4','O36.93X5','O36.93X9','O40.1XX0','O40.1XX1','O40.1XX2','O40.1XX3','O40.1XX4','O40.1XX5','O40.1XX9','O40.2XX0','O40.2XX1','O40.2XX2','O40.2XX3','O40.2XX4','O40.2XX5','O40.2XX9','O40.3XX0','O40.3XX1','O40.3XX2','O40.3XX3','O40.3XX4','O40.3XX5','O40.3XX9','O40.9XX0','O40.9XX1','O40.9XX2','O40.9XX3','O40.9XX4','O40.9XX5','O40.9XX9','O41.00X0','O41.00X1','O41.00X2','O41.00X3','O41.00X4','O41.00X5','O41.00X9','O41.01X0','O41.01X1','O41.01X2','O41.01X3','O41.01X4','O41.01X5','O41.01X9','O41.02X0','O41.02X1','O41.02X2','O41.02X3','O41.02X4','O41.02X5','O41.02X9','O41.03X0','O41.03X1','O41.03X2','O41.03X3','O41.03X4','O41.03X5','O41.03X9','O41.1010','O41.1011','O41.1012','O41.1013','O41.1014','O41.1015','O41.1019','O41.1020','O41.1021','O41.1022','O41.1023','O41.1024','O41.1025','O41.1029','O41.1030','O41.1031','O41.1032','O41.1033','O41.1034','O41.1035','O41.1039','O41.1090','O41.1091','O41.1092','O41.1093','O41.1094','O41.1095','O41.1099','O41.1210','O41.1211','O41.1212','O41.1213','O41.1214','O41.1215','O41.1219','O41.1220','O41.1221','O41.1222','O41.1223','O41.1224','O41.1225','O41.1229','O41.1230','O41.1231','O41.1232','O41.1233','O41.1234','O41.1235','O41.1239','O41.1290','O41.1291','O41.1292','O41.1293','O41.1294','O41.1295','O41.1299','O41.1410','O41.1411','O41.1412','O41.1413','O41.1414','O41.1415','O41.1419','O41.1420','O41.1421','O41.1422','O41.1423','O41.1424','O41.1425','O41.1429','O41.1430','O41.1431','O41.1432','O41.1433','O41.1434','O41.1435','O41.1439','O41.1490','O41.1491','O41.1492','O41.1493','O41.1494','O41.1495','O41.1499','O41.8X10','O41.8X11','O41.8X12','O41.8X13','O41.8X14','O41.8X15','O41.8X19','O41.8X20','O41.8X21','O41.8X22','O41.8X23','O41.8X24','O41.8X25','O41.8X29','O41.8X30','O41.8X31','O41.8X32','O41.8X33','O41.8X34','O41.8X35','O41.8X39','O41.8X90','O41.8X91','O41.8X92','O41.8X93','O41.8X94','O41.8X95','O41.8X99','O41.90X0','O41.90X1','O41.90X2','O41.90X3','O41.90X4','O41.90X5','O41.90X9','O41.91X0','O41.91X1','O41.91X2','O41.91X3','O41.91X4','O41.91X5','O41.91X9','O41.92X0','O41.92X1','O41.92X2','O41.92X3','O41.92X4','O41.92X5','O41.92X9','O41.93X0','O41.93X1','O41.93X2','O41.93X3','O41.93X4','O41.93X5','O41.93X9','O42.00','O42.011','O42.012','O42.013','O42.019','O42.02','O42.10','O42.111','O42.112','O42.113','O42.119','O42.12','O42.90','O42.911','O42.912','O42.913','O42.919','O42.92','O43.011','O43.012','O43.013','O43.019','O43.021','O43.022','O43.023','O43.029','O43.101','O43.102','O43.103','O43.109','O43.111','O43.112','O43.113','O43.119','O43.121','O43.122','O43.123','O43.129','O43.191','O43.192','O43.193','O43.199','O43.211','O43.212','O43.213','O43.219','O43.221','O43.222','O43.223','O43.229','O43.231','O43.232','O43.233','O43.239','O43.811','O43.812','O43.813','O43.819','O43.891','O43.892','O43.893','O43.899','O43.90','O43.91','O43.92','O43.93','O44.00','O44.01','O44.02','O44.03','O44.10','O44.11','O44.12','O44.13','O45.001','O45.002','O45.003','O45.009','O45.011','O45.012','O45.013','O45.019','O45.021','O45.022','O45.023','O45.029','O45.091','O45.092','O45.093','O45.099','O45.8X1','O45.8X2','O45.8X3','O45.8X9','O45.90','O45.91','O45.92','O45.93','O46.001','O46.002','O46.003','O46.009','O46.011','O46.012','O46.013','O46.019','O46.021','O46.022','O46.023','O46.029','O46.091','O46.092','O46.093','O46.099','O46.8X1','O46.8X2','O46.8X3','O46.8X9','O46.90','O46.91','O46.92','O46.93','O47.00','O47.02','O47.03','O47.1','O47.9','O48.0','O48.1','O60.00','O60.02','O60.03','O71.00','O71.02','O71.03','O88.011','O88.012','O88.013','O88.019','O88.111','O88.112','O88.113','O88.119','O88.211','O88.212','O88.213','O88.219','O88.311','O88.312','O88.313','O88.319','O88.811','O88.812','O88.813','O88.819','O90.3','O91.011','O91.012','O91.013','O91.019','O91.111','O91.112','O91.113','O91.119','O91.211','O91.212','O91.213','O91.219','O92.011','O92.012','O92.013','O92.019','O92.111','O92.112','O92.113','O92.119','O92.20','O92.29','O98.011','O98.012','O98.013','O98.019','O98.111','O98.112','O98.11

24

3','O98.119','O98.211','O98.212','O98.213','O98.219','O98.311','O98.312','O98.313','O98.319','O98.411','O98.412','O98.413','O98.419','O98.511','O98.512','O98.513','O98.519','O98.611','O98.612','O98.613','O98.619','O98.711','O98.712','O98.713','O98.719','O98.811','O98.812','O98.813','O98.819','O98.911','O98.912','O98.913','O98.919','O99.011','O99.012','O99.013','O99.019','O99.111','O99.112','O99.113','O99.119','O99.210','O99.211','O99.212','O99.213','O99.280','O99.281','O99.282','O99.283','O99.310','O99.311','O99.312','O99.313','O99.320','O99.321','O99.322','O99.323','O99.330','O99.331','O99.332','O99.333','O99.340','O99.341','O99.342','O99.343','O99.350','O99.351','O99.352','O99.353','O99.411','O99.412','O99.413','O99.419','O99.511','O99.512','O99.513','O99.519','O99.611','O99.612','O99.613','O99.619','O99.711','O99.712','O99.713','O99.719','O99.810','O99.820','O99.830','O99.840','O99.841','O99.842','O99.843','O99.89','O9A.111','O9A.112','O9A.113','O9A.119','O9A.211','O9A.212','O9A.213','O9A.219','O9A.311','O9A.312','O9A.313','O9A.319','O9A.411','O9A.412','O9A.413','O9A.419','O9A.511','O9A.512','O9A.513','O9A.519','Z33.1','Z34.00','Z34.01','Z34.02','Z34.03','Z34.80','Z34.81','Z34.82','Z34.83','Z34.90','Z34.91','Z34.92','Z34.93','Z36']

Encounter, Performed: Blood Pressure Visit

'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000'],'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','99350','99385','99386','99387','99395','99396','99397']

Physical Exam, Performed: Delta systolic blood pressure

'LOINC':['71789-2']

Physical Exam, Performed: Systolic Blood Pressure

'LOINC':['8480-6']

Procedure, Performed: Hemodialysis

'SNOMED-CT':['302497006'],'CPT':['90951','90952','90953','90954','90955','90956','90957','90958','90959','90960','90961','90962','90963','90964','90965','90966','90967','90968','90969','90970','99512']

Procedure, Performed: Kidney Transplant

'SNOMED-CT':['175899003','175901007','175902000','236138007','313030004','48994000','52213001','70536003','88930008'],'CPT':['50340','50360','50365','50370','50380'],'HCPCS':['S2065']

Procedure, Performed: Peritoneal Dialysis

'SNOMED-CT':['14684005','225230008','238318009','238319001','238321006','238322004','238323009','428648006','676002','71192002'],'CPT':['90945','90947','90951','90952','90953','90954','90955','90956','90957','90958','90959','90960','90961','90962','90963','90964','90965','90966','90967','90968','90969','90970']


'CDC Race':['2135-2','2186-5']

Patient Characteristic Payer: Payer 'Source of Payment Typology':['1','11','111','112','113','119','12','121','122','123','129','19','2','21','211','212','213','219','22','23','24','25','29','3','31','311','3111','3112','3113','3114','3115','3116','3119','312','3121','3122','3123','313','32','321','3211','3212','32121','32122','32123','32124','32125','32126','322','3221','3222','3223','3229','33','331','332','333','334','34','341','342','343','349','35','36','361','362','369','37','371','3711','3712','3713','372','379','38','381','3811','3812','3813','3819','382','389','39','4','41','42','43','44','5','51','511','512','513','514','515','519','52','521','522','523','529','53','54','55','59','6','61','611','612','613','619','62','63','64','69','7','71','72','73','79','8','81','82','821','822','823','83','84','85','89','9','91','92','93','94','95','951','953','954','959','96','98','99','9999']

Patient Characteristic Race: Race 'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']Patient Characteristic Sex: ONC 'AdministrativeGender':['F','M']

25

Administrative Sex

5. Diabetes: Foot exam

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS123v5_2.htmleMeasure Title Diabetes: Foot Exam



NQF Number 0056 GUID c0d72444-7c26-4863-9b51-8080f8928a85





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







THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].



Stratification None



Rationale As the seventh leading cause of death in the U.S., diabetes kills approximately 75,000 people a year (CDC FastStats 2015). Diabetes is a group of diseases marked by high blood glucose levels, resulting from the body's inability to produce or use insulin (CDC Statistics 2014, ADA Basics 2013). People with diabetes are at increased risk of serious health complications including vision loss, heart disease, stroke, kidney failure, amputation of toes, feet or legs, and

26


premature death. (CDC Fact Sheet 2014).


Complications due to improper or poor quality of foot care in diabetics can include amputations of the toe, foot, lower and upper leg. Between 1993 and 2009, the CDC monitored the rates of nontraumatic amputations in the diabetic population. Overall, the rates peaked in 1996 with toe amputations at 3.7 per 1,000 diabetic population. Amputations for the foot, lower leg, and upper leg were 1.5, 2.3, and 1.1 per 1,000 diabetic population, respectively, in 1996. Since the late nineties, lower extremity amputation rates in the diabetic population have declined, witnessed by the following rates in 2009: for toe amputations (1.8 per 1,000 diabetic population), followed by lower leg (0.9), foot (0.5) and upper leg (0.4) amputations (CDC, 2012).


American Diabetes Association (2015) Guidelines/ Recommendations: Perform annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation (10-g monofilament plus testing any one of: vibration using 128-Hz tuning fork, pinprick sensation, ankle reflexes, or vibration perception threshold).

Improvement Notation

Higher score indicates better quality

Reference American Diabetes Association. Microvascular complications and foot care. Sec. 9. In Standards of Medical Care in Diabetesd2015. Diabetes Care 2015;38(Suppl. 1):S58-S66

Reference American Diabetes Association (ADA). 2013. Diabetes Statistics. Retrieved from http://www.diabetes.org/diabetes-basics/diabetes-statistics/.

Reference Centers for Disease Control and Prevention (CDC). 2012. CDC's Diabetes Program-Data and Trends-Diabetes Surveillance System-Nontraumatic Lower Extremity Amputation with Diabetes by Level of Amputation. Retrieved from http://www.cdc.gov/diabetes/statistics/lealevel/fig8.htm.





Reference American Diabetes Association (ADA). April 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. Vol. 36 no. 41033-46. http://care.diabetesjournals.org/content/36/4/1033.full

Definition Foot exam: visual inspection with either a sensory exam or a pulse exam

Guidance 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





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

Numerator Patients who received visual, pulse and sensory foot examinations during the measurement period



None




o AND: "Diagnosis: Diabetes" overlaps "Measurement Period"o AND: Age >= 18 year(s) at: "Measurement Period"o AND: Age < 75 year(s) at: "Measurement Period"

27

o AND: Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up" "Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Annual Wellness Visit" during "Measurement Period"


Denominator Exclusions =o OR: "Diagnosis: Bilateral amputation of leg below or above knee" starts before end of "Measurement Period"o 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 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 end of "Measurement Period"

Numerator =o AND: "Physical Exam, Performed: Visual Exam of Foot" during "Measurement Period"o AND: "Physical Exam, Performed: Sensory Exam of Foot" during "Measurement Period"o AND: "Physical Exam, Performed: Pulse Exam of Foot" during "Measurement Period"





Table 5. Data elements from CMS123v5Data element CodesDiagnosis: Bilateral amputation of leg below or above knee

'ICD-9-CM':['897.6','897.7'],'ICD-10-CM':['Q72.03','Q72.23']

Diagnosis: Diabetes 'SNOMED-CT':['190330002','190331003','190368000','190369008','190372001','190389009','190390000','199223000','199225007','199226008','199227004','199228009','199229001','199230006','23045005','237599002','237618001','237627000','28032008','313435000','313436004','314771006','314772004','314893005','314902007','314903002','314904008','359642000','44054006','46635009','4783006','75682002','76751001','81531005','9859006'],'ICD-9-CM':['250.00','250.01','250.02','250.03','250.10','250.11','250.12','250.13','250.20','250.21','250.22','250.23','250.30','250.31','250.32','250.33','250.40','250.41','250.42','250.43','250.50','250.51','250.52','250.53','250.60','250.61','250.62','250.63','250.70','250.71','250.72','250.73','250.80','250.81','250.82','250.83','250.90','250.91','250.92','250.93','357.2','362.01','362.02','362.03','362.04','362.05','362.06','362.07','366.41','648.00','648.01','648.02','648.03','648.04'],'ICD-10-CM':['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','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','E11.329','E11.331','E11.339','E11.341','E11.349','E11.351','E11.359','E11.36','E11.3

28

9','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','E13.329','E13.331','E13.339','E13.341','E13.349','E13.351','E13.359','E13.36','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']},'2.16.840.1.113883.3.464.1003.101.12.1016':{'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']},'

Diagnosis: Left Unilateral Amputation Above or Below Knee

'SNOMED-CT':['308096001','308098000'],'ICD-10-CM':['Q72.22','S78.012A','S78.012D','S78.112A','S78.112D','S88.012A','S88.012D','S88.112A','S88.112D','S88.112S','S88.912S','Z89.512','Z89.522','Z89.612','Z89.622']

Diagnosis: Right Unilateral Amputation Above or Below Knee

'SNOMED-CT':['308095002','308097005'],'ICD-10-CM':['Q72.21','S78.011A','S78.011D','S78.111A','S78.111D','S88.011A','S88.011D','S88.111A','S88.111D','S88.111S','S88.911S','Z89.511','Z89.521','Z89.611','Z89.621']

Diagnosis: Unilateral Amputation Below or Above Knee, Unspecified Laterality

'SNOMED-CT':['110470001','11228000','12663001','265735000','265736004','298049006','298050006','38162008','397163000','397164006','397166008','397167004','397168009','397169001','443025009','6661001','76017008','79733001','83574003','87562003','88312006'],'ICD-9-CM':['897.0','897.1','897.2','897.3','V49.75','V49.76','V49.77'],'ICD-10-CM':['Q72.20']


'HCPCS':['G0438','G0439']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']


'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']

Encounter, Performed: Office Visit 'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']}


'CPT':['99395','99396','99397']


'CPT':['99385','99386','99387']

Physical Exam, Performed: Pulse Exam of Foot

'SNOMED-CT':['91161007']

Physical Exam, Performed: Sensory Exam of Foot

'SNOMED-CT':['134388005']

Physical Exam, Performed: Visual Exam of Foot

'SNOMED-CT':['401191002']

Anatomical location site: Left 'SNOMED-CT':['419161000','7771000']Anatomical location site: Right 'SNOMED-CT':['24028007','419465000']

29


'CDC Race':['2135-2','2186-5']

Patient Characteristic Payer: Payer 'Source of Payment Typology':['1','11','111','112','113','119','12','121','122','123','129','19','2','21','211','212','213','219','22','23','24','25','29','3','31','311','3111','3112','3113','3114','3115','3116','3119','312','3121','3122','3123','313','32','321','3211','3212','32121','32122','32123','32124','32125','32126','322','3221','3222','3223','3229','33','331','332','333','334','34','341','342','343','349','35','36','361','362','369','37','371','3711','3712','3713','372','379','38','381','3811','3812','3813','3819','382','389','39','4','41','42','43','44','5','51','511','512','513','514','515','519','52','521','522','523','529','53','54','55','59','6','61','611','612','613','619','62','63','64','69','7','71','72','73','79','8','81','82','821','822','823','83','84','85','89','9','91','92','93','94','95','951','953','954','959','96','98','99','9999']

Patient Characteristic Race: Race 'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']Patient Characteristic Sex: ONC Administrative Sex


6. Diabetes: Medical Attention for Nephropathy

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS134v5_2.htmleMeasure Title Diabetes: Medical Attention for Nephropathy



NQF Number 0062 GUID 7b2a9277-43da-4d99-9bee-6ac271a07747





Description The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.





CPT(R) contained in the Measure specifications is copyright 2004-2015 American Medical Association. LOINC(R) copyright 2004-2015 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2015 International Health Terminology Standards Development Organisation. ICD-10 copyright 2015 World Health

30


Organization. All Rights Reserved.





Stratification None





In 2011, diabetes accounted for 44% of new kidney failure cases. In the same year, 49,677 diabetics started treatment for kidney failure and 228,924 people of all ages with kidney failure due to diabetes were living on chronic dialysis or with a kidney transplant (CDC Statistics, 2014).


American Diabetes Association (2015):

Screening- At least once a year, quantitatively assess urinary albumin (eg, urine albuminto-creatinine ratio [UACR]) and estimated glomerular filtration rate (eGFR) in patients with type 1 diabetes duration of greater than or equal to 5 years and in all patients with type 2 diabetes. (Level of evidence: B)

Treatment- An angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) is not recommended for the primary prevention of diabetic kidney disease in patients with diabetes who have normal blood pressure and normal UACR (<30 mg/g). (Level of evidence: B)- Either an ACE inhibitor or ARB is suggested for the treatment of the nonpregnant patient with modestly elevated urinary albumin excretion (30-299 mg/day) (Level of evidence: C) and is recommended for those with urinary albumin excretion >=300 mg/day. (Level of evidence: A)- When ACE inhibitors, ARBs, or diuretics are used, monitor serum creatinine and potassium levels for the development of increased creatinine or changes in potassium. (Level of evidence: E)- Continued monitoring of UACR in patients with albuminuria is reasonable to assess progression of diabetic kidney disease. (Level of evidence: E)

American Association of Clinical Endocrinologists (2015): - Beginning 5 years after diagnosis in patients with type 1 diabetes (if diagnosed before age 30) or at diagnosis in patients with type 2 diabetes and those with type 1 diabetes diagnosed after age 30, annual assessment of serum creatinine to determine the estimated glomerular filtration rate (eGFR) and urine albumin excretion rate (AER) should be performed to identify, stage, and monitor progression of diabetic nephropathy (Grade C; best evidence level 3).

31

- Patients with nephropathy should be counseled regarding the need for optimal glycemic control, blood pressure control, dyslipidemia control, and smoking cessation (Grade B; best evidence level 2). - In addition, they should have routine monitoring of albuminuria, kidney function electrolytes, and lipids (Grade B; best evidence level 2). - Associated conditions such as anemia and bone and mineral disorders should be assessed as kidney function declines (Grade D; best evidence level 4). - Referral to a nephrologist is recommended well before the need for renal replacement therapy (Grade D; best evidence level 4).



Reference American Diabetes Association. Microvascular complications and foot care. Sec. 9. In Standards of Medical Care in Diabetesd2015. Diabetes Care 2015;38(Suppl. 1):S58-S66.

Reference American Diabetes Association. 2013. Diabetes Basics. www.diabetes.org/diabetes-basics/?loc=GlobalNavDB.

Reference American Diabetes Association (ADA). April 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. Vol. 36 no. 4 1033-46. http://care.diabetesjournals.org/content/36/4/1033.full.




Reference Handelsman Y, Bloomgarden ZT, Grunberger G, Umpierrez G, Zimmerman RS, Bailey TS, et al. (2015) American Association of Clinical Endocrinologists and American College of Endocrinology-Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan-2015. Endocr Pract 21 Suppl 1: 1-87.

Definition None

Guidance 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





None

Numerator Patients with a screening for nephropathy or evidence of nephropathy during the measurement period

Numerator Exclusions

Not Applicable


None



Population Criteria

32

Initial Population =o AND: Age>= 18 year(s) at: "Measurement Period"o AND: Age< 75 year(s) at: "Measurement Period"o AND: "Diagnosis: Diabetes" overlaps "Measurement Period"o AND: Union of:




Numerator =o AND:

OR: Union of: "Medication, Active: ACE Inhibitor or ARB" "Diagnosis: Hypertensive Chronic Kidney Disease" "Diagnosis: Kidney Failure" "Diagnosis: Glomerulonephritis and Nephrotic Syndrome" "Diagnosis: Diabetic Nephropathy" "Diagnosis: Proteinuria" overlaps "Measurement Period"

OR: Union of: "Procedure, Performed: Kidney Transplant" "Procedure, Performed: Vascular Access for Dialysis" "Procedure, Performed: Dialysis Services" "Intervention, Performed: Other Services Related to Dialysis" "Intervention, Performed: Dialysis Education" "Encounter, Performed: ESRD Monthly Outpatient Services" "Laboratory Test, Performed: Urine Protein Tests (result)" during "Measurement Period"





Table 6. Data elements from CMS134v5Data element CodesDiagnosis: Diabetes 'SNOMED-CT':

['190330002','190331003','190368000','190369008','190372001','190389009','190390000','199223000','199225007','199226008','199227004','199228009','199229001','199230006','23045005','237599002','237618001','237627000','28032008','313435000','313436004','314771006','314772004','314893005','314902007','314903002','314904008','359642000','44054006','46635009','4783006','75682002','76751001','81531005','9859006'],'ICD-9-CM':['250.00','250.01','250.02','250.03','250.10','250.11','250.12','250.13','250.20','250.21','250.22','250.23','250.30','250.31','250.32','250.33','250.40','250.41','250.42','250.43','250.50','250.51','250.52','250.53','250.60','250.61','250.62','250.63','250.70','250.71','250.72','250.73','250.80','250.81','250.82','250.83','250.90','250.91','250.92','250.93','357.2','362.01','362.02','362.03','362.04','362.05','362.06','362.07','366.41','648.00','648.01','648.02','648.03','648.04'],'ICD-10-CM':['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','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.

33

9','E11.00','E11.01','E11.21','E11.22','E11.29','E11.311','E11.319','E11.321','E11.329','E11.331','E11.339','E11.341','E11.349','E11.351','E11.359','E11.36','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','E13.329','E13.331','E13.339','E13.341','E13.349','E13.351','E13.359','E13.36','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']

Diagnosis: Diabetic Nephropathy

'SNOMED-CT':['127013003','236499007','236500003','38046004','401110002','420514000','420715001','421305000','421986006','445170001','54181000'],'ICD-9-CM':['250.41','250.42','250.43'],'ICD-10-CM':['E08.21','E08.22','E08.29','E09.21','E09.22','E09.29','E10.21','E10.22','E10.29','E11.21','E11.22','E11.29','E13.21','E13.22','E13.29']

Diagnosis: Glomerulonephritis and Nephrotic Syndrome

'SNOMED-CT':['110996009','111395007','118951003','123609007','123610002','123752003','13335004','1426004','16726004','1776003','19351000','197579006','197580009','197582001','197584000','197585004','197589005','197590001','197591002','197593004','197594005','197595006','197596007','197597003','197598008','197599000','197600002','197601003','197603000','197605007','197607004','197613008','197614002','197616000','197617009','197618004','197619007','197626007','197628008','197629000','197632002','197661001','197663003','197664009','197670003','197671004','197679002','197681000','197682007','197683002','197684008','197685009','197686005','197687001','197688006','197689003','197690007','197691006','197692004','197693009','197694003','197695002','197696001','197697005','197707007','197708002','197709005','197712008','197713003','197714009','197715005','197716006','197717002','197719004','197720005','197721009','197722002','197723007','197724001','197725000','197738008','197739000','20917003','22702000','234485006','236380004','236381000','236382007','236383002','236384008','236385009','236391006','236392004','236393009','236394003','236395002','236397005','236398000','236399008','236400001','236401002','236402009','236403004','236404005','236405006','236407003','236409000','236410005','236411009','236412002','236413007','236414001','236415000','236416004','236417008','236418003','236419006','236420000','236422008','236437007','236460004','236461000','236463002','236479001','236480003','236508005','236534002','236535001','236587002','236588007','236589004','236590008','239932005','24790002','253864004','25821008','266549004','276585000','282364005','309426007','35546006','359694003','36171008','363234001','3704008','370494002','37085009','38046004','399190000','399340005','40233000','425384007','425455002','441815006','444977005','445258009','445388002','445404003','446923008','44785005','48796009','51055000','52254009','52845002','54181000','54879000','55652009','57965003','58574008','59479006','61165007','61503006','62240004','63510008','64168005','64212008','68544003','68779003','73305009','75888001','7703001','77182004','7724006','80321008','81363003','81475007','8199003','83866005','86210009','90493000'],'ICD-9-CM':['580.4','580.81','580.89','580.9','581.0','581.1','581.2','581.3','581.81','581.89','581.9','582.0','582.1','582.2','582.4','582.81','582.89','582.9','583.0','583.1','583.2','583.4','583.6','583.7','583.81','583.89','583.9','588.0','588.1','588.81','588.89','588.9'],'ICD-10-CM':['N00.0','N00.1','N00.2','N00.3','N00.4','N00.5','N00.6','N00.7','N00.8','N00.9','N01.0','N01.1','N01.2','N01.3','N01.4','N01.5','N01.6','N01.7','N01.8','N01.9','N02.0','N02.1','N02.2','N02.3','N02.4','N02.5','N02.6','N02.7','N02.8','N02.9','N03.0','N03.1','N03.2','N03.3','N03.4','N03.5','N03.6','N03.7','N03.8','N03.9','N04.0','N04.1','N04.2','N04.3','N04.4','N04.5','N04.6','N04.7','N04.8','N04.9','N05.0','N05.1','N05.2','N05.3','N05.4','N05.5','N05.6','N05.7','N05.8','N05.9','N06.0','N06.1','N06.2','N06.3','N06.4','N06.5','N06.6','N06.7','N06.8','N06.9','N07.0','N07.1','N07.2','N07.3','N07.4','N07.5','N07.6','N07.7','N07.8','N07.9','N08','N25.0','N25.1','N25.81','N25.89','N25.9']

34

Diagnosis: Hypertensive Chronic Kidney Disease

'SNOMED-CT':['111438007','123799005','123800009','14973001','193003','194774006','194783001','19769006','23130000','28119000','285831000119108','285841000119104','286371000119107','32916005','38481006','39018007','397748008','427889009','428575007','473392002','49220004','57684003','62240004','65443008','66052004','66610008','73410007','78544004','81363003','86234004','90493000'],'ICD-9-CM':['403.01','403.10','403.11','403.90','403.91','404.00','404.01','404.02','404.03','404.10','404.11','404.12','404.13','404.90','404.91','404.92','404.93'],'ICD-10-CM':['I12.0','I12.9','I13.0','I13.10','I13.11','I13.2']

Diagnosis: Kidney Failure 'SNOMED-CT':['129151000119102','129171000119106','129181000119109','140111000119107','140131000119102','145681000119101','14669001','236434000','236435004','236436003','284981000119102','285001000119105','285861000119100','285881000119109','429224003','431855005','431857002','433144002','433146000','46177005','700378005','700379002','711000119100','721000119107','731000119105','90741000119107','90751000119109','96721000119103','96731000119100','96741000119109'],'ICD-9-CM':['584.5','584.6','584.7','584.8','584.9','585.1','585.2','585.3','585.4','585.5','585.6','585.9','586','587'],'ICD-10-CM':['N17.0','N17.1','N17.2','N17.8','N17.9','N18.1','N18.2','N18.3','N18.4','N18.5','N18.6','N18.9','N19']

Diagnosis: Proteinuria 'SNOMED-CT':['12178007','167582007','263808002','264867001','274769005','29738008','312975006','34993002'],'ICD-9-CM':['791.0'],'ICD-10-CM':['R80.1','R80.8','R80.9']},


'HCPCS':['G0438','G0439']

Encounter, Performed: ESRD Monthly Outpatient Services

'CPT':['90957','90958','90959','90960','90961','90962','90965','90966','90969','90970','90989','90993','90997','90999','99512']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']


'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']


'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']


'CPT':['99395','99396','99397']


'CPT':['99385','99386','99387']

Intervention, Performed: Dialysis Education

'SNOMED-CT':['28812006','385972005','59596005','66402002']

Intervention, Performed: Other Services Related to Dialysis

'SNOMED-CT':['233591003','251000124108','311000124103','3257008','385970002','385971003','385973000','406168002','73257006']

Laboratory Test, Performed: Urine Protein Tests

'LOINC':['11218-5','12842-1','13705-9','13801-6','14585-4','14956-7','14957-5','14958-3','14959-1','1753-3','1754-1','1755-8','1757-4','18373-1','20454-5','20621-9','21059-

35

1','21482-5','26801-1','27298-9','2887-8','2888-6','2889-4','2890-2','30000-4','30001-2','30003-8','32209-9','32294-1','32551-4','34366-5','35663-4','40486-3','40662-9','40663-7','43605-5','43606-3','43607-1','44292-1','47558-2','49023-5','50561-0','50949-7','53121-0','53525-2','53530-2','53531-0','53532-8','56553-1','57369-1','57735-3','5804-0','58448-2','58992-9','59159-4','60678-0','63474-1','9318-7']

Medication, Active: ACE Inhibitor or ARB

'RxNorm':['1000001','1011718','1011729','1091646','1091652','1235144','1235151','1299859','1299871','1299890','1299896','1299897','1435624','153822','153823','1600716','1600724','1600728','1656340','1656349','1656354','197436','197437','197438','197439','197884','197885','197886','197887','198188','198189','199351','199352','199353','199622','199707','199708','199709','199816','199817','199850','199919','199937','200094','200095','200096','200284','200285','205304','205305','205326','247516','249851','251856','261962','282755','283316','283317','308962','308963','308964','310139','310140','310792','310793','310796','310797','310809','311353','311354','312748','312749','312750','314076','314077','314203','317173','349199','349200','349201','349353','349373','349401','349405','349483','351292','351293','401965','401968','403853','403854','403855','411434','477130','485471','577776','578325','578330','636042','636045','639537','722126','722131','722134','722137','730861','730866','730869','730872','802749','845488','848131','848135','848140','848145','848151','854925','854984','854988','857166','857169','857174','857183','857187','858618','858621','858804','858810','858813','858817','858824','858828','858921','876514','876519','876524','876529','897781','897783','897844','897853','898342','898346','898350','898353','898356','898359','898362','898367','898372','898378','898687','898690','898719','898723','979464','979468','979471','979480','979485','979492','999967','999986','999991','999996']

Procedure, Performed: Dialysis Services

'SNOMED-CT':['108241001','10848006','11932001','14684005','180273006','225230008','225231007','233575001','233576000','233577009','233578004','233579007','233580005','233581009','233582002','233583007','233584001','233585000','233586004','233587008','233588003','233589006','233590002','238316008','238317004','238318009','238319001','238321006','238322004','238323009','265764009','288182009','302497006','34897002','427053002','428648006','439278006','439976001','57274006','676002','67970008','68341005','71192002'],'CPT':['90920','90921','90924','90925','90935','90937','90940','90945','90947'],'HCPCS':['G0257']

Procedure, Performed: Kidney Transplant

'SNOMED-CT':['175899003','175901007','175902000','236138007','313030004','48994000','52213001','70536003','88930008'],'CPT':['50340','50360','50365','50370','50380'],'HCPCS':['S2065']

Procedure, Performed: Vascular Access for Dialysis

'SNOMED-CT':['180272001','180277007','225892009','22800003','233468004','233471007','233472000','233547003','238314006','238315007','271418008','34163007','426340003','427992007','428118009','431418000','431440009','431781000','432509002','432654009','434435000','438341004','438342006','439241008','439322008','439349008','439534001','443683004','448591002','449400003','450865002','54817007','61160002','61740001','63421002','676002','69380006','7459007','79827002','80634002'],'CPT':['36147','36148','36800','36810','36815','36818','36819','36820','36821','36831','36832','36833']


'CDC Race':['2135-2','2186-5']



36


'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']



7. Diabetic retinopathy : Communication with the Physician Managing Ongoing Diabetes Care

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS142v5_3.htmleMeasure Title Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care



NQF Number 0089 GUID 53d6d7c3-43fb-4d24-8099-17e74c022c05


Measure Steward PCPI(R) Foundation (PCPI[R])

Measure Developer American Medical Association (AMA)

Measure Developer PCPI(R) Foundation (PCPI[R])


Description Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months

Copyright Copyright 2015 PCPI(R) Foundation and American Medical Association. All Rights Reserved.

Disclaimer The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain.

Commercial uses of the Measures require a license agreement between the user and the PCPI(R) Foundation (PCPI[R]) or the American Medical Association (AMA). Neither the American Medical Association (AMA), nor the AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), now known as the PCPI, nor their members shall be responsible for any use of the Measures.

The National Committee for Quality Assurance's significant past efforts and contributions to the development and updating of the Measures is acknowledged.

AMA and PCPI encourage use of the Measures by other health care professionals, where appropriate.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, PCPI, and its members and former members of the AMA-PCPI disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2015 American Medical Association. LOINC(R) is copyright 2004-2015 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2015 International Health Terminology Standards Development Organisation. ICD-10 is copyright 2015 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].



Stratification None


37



Rationale The primary care physician that manages the ongoing care of the patient with diabetes should be aware of the patient's dilated eye examination and severity of retinopathy to manage the ongoing diabetes care. Such communication is important in assisting the physician to better manage the diabetes. Several studies have shown that better management of diabetes is directly related to lower rates of development of diabetic eye disease (Diabetes Control and Complications Trial -DCCT, UK Prospective Diabetes Study - UKPDS).


Ophthalmologists should communicate the ophthalmologic findings and level of retinopathy with the primary care physician as well as the need for optimizing metabolic control. (Good evidence; Strong recommendation) (AAO, 2014)


Reference American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern Guidelines. Diabetic Retinopathy. San Francisco, CA: American Academy of Ophthalmology; 2014.

Definition Communication - May include documentation in the medical record indicating that the findings of the dilated macular or fundus exam were communicated (eg, verbally, by letter) with the clinician managing the patient's diabetic care OR a copy of a letter in the medical record to the clinician managing the patient's diabetic care outlining the findings of the dilated macular or fundus exam.

Findings - Includes level of severity of retinopathy (eg, mild nonproliferative, moderate nonproliferative, severe nonproliferative, very severe nonproliferative, proliferative) AND the presence or absence of macular edema.

Guidance The measure, as written, does not specifically require documentation of laterality. Coding limitations in particular clinical terminologies do not currently allow for that level of specificity (ICD-10-CM includes laterality, but ICD-9-CM and SNOMED-CT do not uniformly include this distinction). Therefore, at this time, it is not a requirement of this measure to indicate laterality of the diagnoses, findings or procedures. Available coding to capture the data elements specified in this measure has been provided. It is assumed that the eligible professional will record laterality in the patient medical record, as quality care and clinical documentation should include laterality.

The communication of results to the primary care physician providing ongoing care of a patient's diabetes should be completed soon after the dilated exam is performed. Eligible professionals reporting on this measure should note that all data for the reporting year is to be submitted by the deadline established by CMS. Therefore, eligible professionals who see patients towards the end of the reporting period (ie, December in particular), should communicate the results of the dilated macular exam as soon as possible in order for those patients to be counted in the measure numerator. Communicating the results as soon as possible after the date of the exam will ensure the data are included in the submission to CMS.


Initial Population All patients aged 18 years and older with a diagnosis of diabetic retinopathy

Denominator Equals Initial Population who had a dilated macular or fundus exam performed


None

Numerator Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient's diabetic care



Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes

Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes




o AND: Age>= 18 year(s) at: "Measurement Period"o AND: "Diagnosis: Diabetic Retinopathy" overlaps Occurrence A of $EyeCareEncounters

Denominator =o AND: Initial Populationo AND: "Diagnostic Study, Performed: Macular Exam (result)" during Occurrence A of $EyeCareEncounters


Numerator =

38

o AND: "Communication: From Provider to Provider: Level of Severity of Retinopathy Findings" starts after start of Occurrence A of $EyeCareEncounters

o AND: Union of: "Communication: From Provider to Provider: Macular Edema Findings Present" "Communication: From Provider to Provider: Macular Edema Findings Absent" starts after start of Occurrence A of $EyeCareEncounters


Denominator Exceptions =o OR: Union of:

"Communication: From Provider to Provider not done: Medical Reason" for "Macular Edema Findings Absent" "Communication: From Provider to Provider not done: Patient Reason" for "Macular Edema Findings Absent" "Communication: From Provider to Provider not done: Medical Reason" for "Macular Edema Findings Present" "Communication: From Provider to Provider not done: Patient Reason" for "Macular Edema Findings Present" "Communication: From Provider to Provider not done: Medical Reason" for "Level of Severity of Retinopathy

Findings" "Communication: From Provider to Provider not done: Patient Reason" for "Level of Severity of Retinopathy

Findings" starts after start of Occurrence A of $EyeCareEncounters


Data Criteria (QDM Variables) $EyeCareEncounters =

o Union of: "Encounter, Performed: Ophthalmological Services" "Encounter, Performed: Care Services in Long-Term Residential Facility" "Encounter, Performed: Nursing Facility Visit" "Encounter, Performed: Office Visit" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Face-to-Face Interaction" during "Measurement Period"

Table 7. Data elements from CMS142v5Data elements Codes

Communication: From Provider to Provider: Level of Severity of Retinopathy Findings

SNOMED-CT':['312903003','312904009','312905005','399876000','59276001']

Communication: From Provider to Provider not done: Medical Reason

'SNOMED-CT':['183932001','183964008','183966005','216952002','266721009','269191009','274512008','31438003','35688006','371133007','397745006','407563006','410534003','410536001','416098002','416406003','428119001','445528004','59037007','62014003','79899007']

Communication: From Provider to Provider not done: Patient Reason

'SNOMED-CT':['105480006','160932005','160934006','182890002','182895007','182897004','182900006','182902003','183944003','183945002','184081006','185479006','185481008','224187001','225928004','266710000','266966009','275694009','275936005','281399006','310343007','373787003','385648002','406149000','408367005','413310006','413311005','413312003','416432009','423656007','424739004','443390004']

Communication: From Provider to Provider: Macular Edema Findings Absent

'SNOMED-CT':['428341000124108']

Communication: From Provider to Provider: Macular Edema Findings Present

'SNOMED-CT':['193350004','193387007','232020009','312911008','312912001','312920004','312921000','312922007','314010006','314011005','314014002','314015001','37231002','399864000','420486006','421779007','432789001']

Diagnosis: Diabetic Retinopathy

'SNOMED-CT':['193349004','193350004','232020009','232021008','232022001','232023006','25412000','311782002','312903003','312904009','312905005','312906006','312907002','312908007','312909004','312912001','314010006','314011005','314014002','314015001','390834004','399862001','399863006','399864000','399865004','399866003','399868002','399869005','399870006','39

39

9871005','399872003','399873008','399874002','399875001','399876000','399877009','420486006','420789003','421779007','422034002','4855003','59276001'],'ICD-9-CM':['362.01','362.02','362.03','362.04','362.05','362.06'],'ICD-10-CM':['E08.311','E08.319','E08.321','E08.329','E08.331','E08.339','E08.341','E08.349','E08.351','E08.359','E09.311','E09.319','E09.321','E09.329','E09.331','E09.339','E09.341','E09.349','E09.351','E09.359','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E11.311','E11.319','E11.321','E11.329','E11.331','E11.339','E11.341','E11.349','E11.351','E11.359','E13.311','E13.319','E13.321','E13.329','E13.331','E13.339','E13.341','E13.349','E13.351','E13.359']

Diagnostic Study, Performed: Macular Exam

'LOINC':['32451-7']

Encounter, Performed: Care Services in Long-Term Residential Facility

'CPT':['99324','99325','99326','99327','99328','99334','99335','99336','99337']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']

Encounter, Performed: Nursing Facility Visit

'CPT':['99304','99305','99306','99307','99308','99309','99310']


'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']

Encounter, Performed: Ophthalmological Services

'CPT':['92002','92004','92012','92014']

Encounter, Performed: Outpatient Consultation

'SNOMED-CT':['105480006','160932005','160934006','182890002','182895007','182897004','182900006','182902003','183944003','183945002','184081006','185479006','185481008','224187001','225928004','266710000','266966009','275694009','275936005','281399006','310343007','373787003','385648002','406149000','408367005','413310006','413311005','413312003','416432009','423656007','424739004','443390004']


'CDC Race':['2135-2','2186-5']




'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']



8. Diabetes: Eye exam

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS131v5_2.htmleMeasure Title Diabetes: Eye Exam



40


NQF Number 0055 GUID d90bdab4-b9d2-4329-9993-5c34e2c0dc66





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 period











Stratification None





In 2005-2008, of adults with diabetes aged 40 years or older, 4.2 million (28.5%) people had diabetic retinopathy, damage to the small blood vessels in the retina that may result in loss of vision. (CDC Statistics, 2014).


American Diabetes Association (ADA) (2015):

- Adults with type 1 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist within 5 years after the onset of diabetes. (Level of evidence: B)

- Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by an ophthalmologist or optometrist shortly after the diagnosis of diabetes. (Level of evidence: B)


41

Reference American Diabetes Association. Microvascular complications and foot care. Sec. 9. In Standards of Medical Care in Diabetes 2015. Diabetes Care 2015;38(Suppl. 1):S58-S66

Reference American Diabetes Association. 2009. "Standards of Medical Care in Diabetes-2009." Diabetes Care 2009 32 (Suppl 1):S6-S12. doi:10.2337/dc09-S006.


Reference American Diabetes Association (ADA). April 2013. Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care. Vol. 36 no. 4 1033-46. http://care.diabetesjournals.org/content/36/4/1033.full




Definition None

Guidance 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.

The eye exam must be performed by an ophthalmologist or optometrist.





None

Numerator Patients 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 exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period



None




o AND: "Diagnosis: Diabetes" overlaps "Measurement Period"o AND: Age>= 18 year(s) at: "Measurement Period"o AND: Age< 75 year(s) at: "Measurement Period"o 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"



Numerator =o 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"


Denominator Exceptions =

42

o None Stratification =

o NoneData Criteria (QDM Variables)

NoneTable 8. Data elements from CMS131v5

Data elements CodesDiagnosis: Diabetes 'SNOMED-CT':

['190330002','190331003','190368000','190369008','190372001','190389009','190390000','199223000','199225007','199226008','199227004','199228009','199229001','199230006','23045005','237599002','237618001','237627000','28032008','313435000','313436004','314771006','314772004','314893005','314902007','314903002','314904008','359642000','44054006','46635009','4783006','75682002','76751001','81531005','9859006'],'ICD-9-CM':['250.00','250.01','250.02','250.03','250.10','250.11','250.12','250.13','250.20','250.21','250.22','250.23','250.30','250.31','250.32','250.33','250.40','250.41','250.42','250.43','250.50','250.51','250.52','250.53','250.60','250.61','250.62','250.63','250.70','250.71','250.72','250.73','250.80','250.81','250.82','250.83','250.90','250.91','250.92','250.93','357.2','362.01','362.02','362.03','362.04','362.05','362.06','362.07','366.41','648.00','648.01','648.02','648.03','648.04'],'ICD-10-CM':['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','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','E11.329','E11.331','E11.339','E11.341','E11.349','E11.351','E11.359','E11.36','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','E13.329','E13.331','E13.339','E13.341','E13.349','E13.351','E13.359','E13.36','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']


'HCPCS':['G0438','G0439']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']


'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']


'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']

Encounter, Performed: Ophthalmological Services

'CPT':['92002','92004','92012','92014']


'CPT':['99395','99396','99397']


'CPT':['99385','99386','99387']

Physical Exam, Performed: Retinal or Dilated Eye Exam

'SNOMED-CT':['252779009','252780007','252781006','252782004','252783009','252784003','252788000','252789008','252790004','274795007','274798009','308110009','314971001','314972008','410

43

451008','410452001','410453006','410455004','420213007','425816006','427478009','6615001']

Result: Negative Finding 'SNOMED-CT':['442225006']Patient Characteristic Ethnicity: Ethnicity

'CDC Race':['2135-2','2186-5']




'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']



9. Coronary Artery Disease: Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)

Source: https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms/ecqms-2017-performance-period/coronary-artery-disease

eMeasure Title Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)



NQF Number Not Applicable GUID 80744ae2-de81-4b16-a71d-69522eb865c5


Measure Steward PCPI(R) Foundation (PCPI[R])

Measure Developer American Medical Association (AMA)

Measure Developer PCPI(R) Foundation (PCPI[R])

Endorsed By None

Description Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy

Copyright Copyright 2015 American College of Cardiology, American Heart Association and American Medical Association. All Rights Reserved.

Disclaimer The Measures are not clinical guidelines, do not establish a standard of medical care, and have not been tested for all potential applications.

The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, eg, use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain.

Commercial uses of the Measures require a license agreement between the user and the PCPI(R) Foundation (PCPI[R]), the American Medical Association (AMA), American College of Cardiology (ACC) or the American Heart Association (AHA). Neither the AMA, nor ACC, nor AHA, nor the AMA-convened Physician Consortium for Performance Improvement(R) (AMA-PCPI), now known as the PCPI, nor their members shall be responsible for any use of the Measures.

AMA and PCPI encourage use of the Measures by other health care professionals, where appropriate.

44

https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms/ecqms-2017-performance-period/coronary-artery-disease

https://ecqi.healthit.gov/eligible-professional-eligible-clinician-ecqms/ecqms-2017-performance-period/coronary-artery-disease


Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, ACC, AHA, the PCPI and its members and former members of the AMA-PCPI disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT[R]) or other coding contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2015 American Medical Association. LOINC(R) is copyright 2004-2015 Regenstrief Institute, Inc. This material contains SNOMED CLINICAL TERMS (SNOMED CT[R]) copyright 2004-2015 International Health Terminology Standards Development Organisation (IHTSDO). ICD-10 is copyright 2015 World Health Organization. All Rights Reserved.

Due to technical limitations, registered trademarks are indicated by (R) or [R].



Stratification None


Rate Aggregation Denominator 1: Patients with left ventricular systolic dysfunction (LVEF <40%)Denominator 2: Patients with a prior (resolved) (within the past 3 years) myocardial infarction

Rationale Nonadherence to cardioprotective medications is prevalent among outpatients with coronary artery disease and can be associated with a broad range of adverse outcomes, including all-cause and cardiovascular mortality, cardiovascular hospitalizations, and the need for revascularization procedures.

A patient with a diagnosis of coronary artery disease seen within a 12 month period and LVEF <40% should be taking either bisoprolol, carvedilol, or sustained release metoprolol succinate. While all beta-blockers appear to be of equal efficacy in patients with chronic stable coronary artery disease, these three medications have specifically shown to reduce mortality in patients with reduced LVEF.


Beta-blocker therapy should be started and continued for 3 years in all patients with normal LV function after MI or ACS. (Class I, Level of Evidence: B) (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, 2012)

Beta-blocker therapy should be used in all patients with LV systolic dysfunction (EF <= 40%) with heart failure or prior MI, unless contraindicated. (Use should be limited to carvedilol, metoprolol succinate, or bisoprolol, which have been shown to reduce risk of death.) (Class I, Level of Evidence: A) (ACCF/AHA/ACP/AATS/PCNA/SCAI/STS, 2012)


Reference Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB III, Kligfield PD, Krumholz HM, Kwong RYK, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2012;60:e44-164.

Definition Prescribed may include prescription given to the patient for beta-blocker therapy at one or more visits in the measurement period OR patient already taking beta-blocker therapy as documented in current medication list.

Prior Myocardial Infarction (MI) for denominator 2 is limited to those occurring within the past 3 years.

Guidance Beta-blocker therapy:- For patients with prior MI, beta-blocker therapy includes any agent within the beta-blocker drug class. As of 2015, no recommendations or evidence are cited in current stable ischemic heart disease guidelines for preferential use of specific agents- For patients with prior LVEF <40%, beta-blocker therapy includes the following: bisoprolol, carvedilol, or sustained release metoprolol succinate

The requirement of "Count >=2 of Encounter, Performed" is to establish that the eligible professional has an existing relationship with the patient.


Initial Population All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period

Denominator Equals Initial Population who also have prior (within the past 3 years) MI or a current or prior LVEF <40%

45


None

Numerator Patients who were prescribed beta-blocker therapy



Documentation of medical reason(s) for not prescribing beta-blocker therapy (eg, allergy, intolerance, other medical reasons)Documentation of patient reason(s) for not prescribing beta-blocker therapy (eg, patient declined, other patient reasons)Documentation of system reason(s) for not prescribing beta-blocker therapy (eg, other reasons attributable to the health care system)



Population Criteria

------ Population Criteria 1 ------ Initial Population =

o AND: Age>= 18 year(s) at: "Measurement Period"o AND: Count>= 2 : Union of:

"Encounter, Performed: Office Visit" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Nursing Facility Visit" "Encounter, Performed: Care Services in Long-Term Residential Facility" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Patient Provider Interaction" during "Measurement Period"

o AND: OR: "Diagnosis: Coronary Artery Disease No MI" overlaps Occurrence A of $CADEncounters145 OR: "Procedure, Performed: Cardiac Surgery" starts before end of Occurrence A of $CADEncounters145

Denominator =o AND: Initial Populationo AND: Union of:

"Diagnostic Study, Performed: Ejection Fraction (result < 40 %)" "Diagnosis: Moderate or Severe LVSD" "Diagnosis: Left Ventricular Systolic Dysfunction (severity: Moderate or Severe)" starts before end of Occurrence A of $CADEncounters145


Numerator =o AND:

OR: "Medication, Order: Beta Blocker Therapy for LVSD" during Occurrence A of $CADEncounters145 OR: "Medication, Active: Beta Blocker Therapy for LVSD" overlaps Occurrence A of $CADEncounters145


Denominator Exceptions =o OR:

AND: Most Recent: "Occurrence B of Physical Exam, Performed: Heart Rate" starts before start of "Occurrence A of Physical Exam, Performed: Heart Rate"

AND: "Occurrence A of Physical Exam, Performed: Heart Rate (result < 50 bpm)" during Occurrence A of $CADEncounters145

AND: "Occurrence B of Physical Exam, Performed: Heart Rate (result < 50 bpm)" during Occurrence A of $CADEncounters145

o OR: Union of: "Medication, Order not done: Medical Reason" for "Beta Blocker Therapy Ingredient" "Medication, Order not done: Patient Reason" for "Beta Blocker Therapy Ingredient" "Medication, Order not done: System Reason" for "Beta Blocker Therapy Ingredient" starts during Occurrence A of $CADEncounters145

o OR: Union of: "Diagnosis: Arrhythmia" "Diagnosis: Hypotension" "Diagnosis: Asthma" "Diagnosis: Allergy to Beta Blocker Therapy" "Medication, Intolerance: Beta Blocker Therapy"

46

"Diagnosis: Intolerance to Beta Blocker Therapy" "Diagnosis: Bradycardia" "Medication, Allergy: Beta Blocker Therapy Ingredient" overlaps Occurrence A of $CADEncounters145

o OR: AND: "Diagnosis: Atrioventricular Block" overlaps Occurrence A of $CADEncounters145 AND NOT: "Diagnosis: Cardiac Pacer in Situ" starts before end of Occurrence A of $CADEncounters145 AND NOT: "Device, Applied: Cardiac Pacer" starts before end of Occurrence A of $CADEncounters145


------ Population Criteria 2 ------

Initial Population =o AND: Age>= 18 year(s) at: "Measurement Period"o AND: Count>= 2 : Union of:

"Encounter, Performed: Office Visit" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Nursing Facility Visit" "Encounter, Performed: Care Services in Long-Term Residential Facility" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Patient Provider Interaction" during "Measurement Period"

o AND: OR: "Diagnosis: Coronary Artery Disease No MI" overlaps Occurrence A of $CADEncounters145 OR: "Procedure, Performed: Cardiac Surgery" starts before end of Occurrence A of $CADEncounters145

Denominator =o AND: Initial Populationo AND: "Diagnosis: Myocardial Infarction" <= 3 year(s) ends before start of Occurrence A of $CADEncounters145


Numerator =o AND:

OR: "Medication, Order: Beta Blocker Therapy" during Occurrence A of $CADEncounters145 OR: "Medication, Active: Beta Blocker Therapy" overlaps Occurrence A of $CADEncounters145


Denominator Exceptions =o OR:

AND: Most Recent: "Occurrence B of Physical Exam, Performed: Heart Rate" starts before start of "Occurrence A of Physical Exam, Performed: Heart Rate"

AND: "Occurrence A of Physical Exam, Performed: Heart Rate (result < 50 bpm)" during Occurrence A of $CADEncounters145

AND: "Occurrence B of Physical Exam, Performed: Heart Rate (result < 50 bpm)" during Occurrence A of $CADEncounters145

o OR: Union of: "Medication, Order not done: Medical Reason" for "Beta Blocker Therapy Ingredient" "Medication, Order not done: Patient Reason" for "Beta Blocker Therapy Ingredient" "Medication, Order not done: System Reason" for "Beta Blocker Therapy Ingredient" starts during Occurrence A of $CADEncounters145

o OR: Union of: "Diagnosis: Arrhythmia" "Diagnosis: Hypotension" "Diagnosis: Asthma" "Diagnosis: Allergy to Beta Blocker Therapy" "Medication, Intolerance: Beta Blocker Therapy" "Diagnosis: Intolerance to Beta Blocker Therapy" "Diagnosis: Bradycardia" "Medication, Allergy: Beta Blocker Therapy Ingredient" overlaps Occurrence A of $CADEncounters145

o OR: AND: "Diagnosis: Atrioventricular Block" overlaps Occurrence A of $CADEncounters145 AND NOT: "Diagnosis: Cardiac Pacer in Situ" starts before end of Occurrence A of $CADEncounters145 AND NOT: "Device, Applied: Cardiac Pacer" starts before end of Occurrence A of $CADEncounters145


47

Data Criteria (QDM Variables) $CADEncounters145 =

o Union of: "Encounter, Performed: Office Visit" "Encounter, Performed: Outpatient Consultation" "Encounter, Performed: Nursing Facility Visit" "Encounter, Performed: Care Services in Long-Term Residential Facility" "Encounter, Performed: Home Healthcare Services" "Encounter, Performed: Face-to-Face Interaction" during "Measurement Period"

Table 9. Data elements from CMS145v5.Data element CodesDevice, Applied: Cardiac Pacer 'SNOMED-CT':['14106009','360127006','360128001','424921004','56961003']Diagnosis: Allergy to Beta Blocker Therapy

'SNOMED-CT':['293962009','293963004','293964005','293965006','293966007','293967003','293968008','293969000','293970004','293971000','293972007','293973002','293974008','293975009','293976005','293977001','293978006','293979003','293980000','293981001','293982008','293983003','293984009']

Diagnosis: Arrhythmia 'SNOMED-CT':['10164001','10626002','11157007','11849007','13640000','17338001','17366009','17869006','184004','195060002','195071001','195072008','195083004','233891009','233892002','233893007','233894001','233895000','233904005','233915000','233922008','233923003','234172002','251161003','251162005','251163000','251164006','251165007','251166008','251167004','251168009','251170000','251172008','251173003','251174009','251175005','251176006','251177002','251178007','251179004','251180001','251181002','251182009','251186007','251187003','251188008','26950008','27337007','276796006','284470004','287057009','29320008','309809007','33413000','36083008','38274001','39260000','39357005','40593004','406461004','418341009','418818005','419752005','421869004','422348008','429243003','44808001','47830009','49982000','55475008','59272004','60423000','61277005','63232000','63593006','69730002','71908006','72654001','74390002','74615001','75532003','81681009','81898007','88412007'],'ICD-9-CM':['427.89','427.9'],'ICD-10-CM':['I49.8','I49.9']},'

Diagnosis: Asthma 'SNOMED-CT':['11641008','12428000','13151001','195949008','195967001','195977004','225057002','233672007','233678006','233679003','233683003','233688007','266361008','281239006','30352005','304527002','31387002','370218001','370219009','370220003','370221004','389145006','405944004','407674008','409663006','423889005','424199006','424643009','425969006','426656000','426979002','427295004','427603009','427679007','442025000','55570000','56968009','59786004','63088003','707445000','707446004','707447008','708038006','708090002','708093000','708094006','708095007','708096008','85761009','92807009','93432008'],'ICD-9-CM':['493.00','493.01','493.02','493.10','493.11','493.12','493.20','493.21','493.22','493.81','493.82','493.90','493.91','493.92'],'ICD-10-CM':['J45.20','J45.21','J45.22','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','J45.998']

Diagnosis: Atrioventricular Block

'SNOMED-CT':['195042002','233917008','233918003','251114004','27885002','28189009','283645003','54016002','93130009'],'ICD-9-CM':['426.0','426.12','426.13'],'ICD-10-CM':['I44.1','I44.2']

Diagnosis: Bradycardia 'SNOMED-CT':['251162005','29894000','397841007','44602002','49044005','49710005'],'ICD-9-CM':['427.81','427.89'],'ICD-10-CM':['I49.5','I49.8','R00.1']

Diagnosis: Cardiac Pacer in 'SNOMED-CT':['441509002'],

48

Situ 'ICD-9-CM':['V45.01'],'ICD-10-CM':['Z95.0']

Diagnosis: Coronary Artery Disease No MI

'SNOMED-CT':['10365005','123641001','123642008','19057007','194823009','194828000','194842008','194843003','21470009','233817007','233819005','233821000','233970002','28248000','29899005','300995000','314116003','315025001','315348000','35928006','371803003','371804009','371805005','371806006','371807002','371808007','371809004','371810009','371811008','371812001','398274000','408546009','41334000','420006002','421327009','427919004','429245005','429559004','443502000','4557003','50570003','53741008','59021001','61490001','62207008','63739005','66189004','67682002','74218008','75398000','85284003','87343002','89323001','92517006'],'ICD-9-CM':['411.0','411.1','411.81','411.89','413.0','413.1','413.9','414.00','414.01','414.02','414.03','414.04','414.05','414.06','414.07','414.2','414.3','414.8','414.9','V45.81','V45.82'],'ICD-10-CM':['I20.0','I20.1','I20.8','I20.9','I24.0','I24.1','I24.8','I24.9','I25.10','I25.110','I25.111','I25.118','I25.119','I25.5','I25.6','I25.700','I25.701','I25.708','I25.709','I25.710','I25.711','I25.718','I25.719','I25.720','I25.721','I25.728','I25.729','I25.730','I25.731','I25.738','I25.739','I25.750','I25.751','I25.758','I25.759','I25.760','I25.761','I25.768','I25.769','I25.790','I25.791','I25.798','I25.799','I25.810','I25.811','I25.812','I25.82','I25.83','I25.89','I25.9','Z95.1','Z95.5','Z98.61']

Diagnosis: Hypotension 'SNOMED-CT':['195506001','200113008','200114002','230664009','234171009','271870002','286963007','371073003','408667000','408668005','429561008','45007003','61933008','70247006','75181005','77545000','88887003'],'ICD-9-CM':['458.0','458.1','458.21','458.29','458.8','458.9'],'ICD-10-CM':['I95.0','I95.1','I95.2','I95.3','I95.81','I95.89','I95.9']

Diagnosis: Intolerance to Beta Blocker Therapy

'SNOMED-CT':['292419005','292420004','292421000','292424008','292425009','292426005','292427001','292428006','292429003','292430008','292431007','292432000','292433005','292434004','292435003','292436002','292437006','292438001','292439009','292440006','292441005','292442003','418370000']

Diagnosis: Left Ventricular Systolic Dysfunction

'SNOMED-CT':['134401001']

Diagnosis: Moderate or Severe LVSD

'SNOMED-CT':['981000124106','991000124109']

Diagnosis: Myocardial Infarction

'SNOMED-CT':['10273003','129574000','15990001','161502000','161503005','1755008','194802003','194809007','194856005','22298006','233835003','233838001','233839009','233840006','233841005','233842003','233843008','275905002','30277009','304914007','307140009','308065005','314207007','32574007','371068009','394710008','399211009','401303003','401314000','418044006','42531007','428196007','428752002','52035003','54329005','57054005','58612006','62695002','65547006','70211005','70422006','73795002','79009004'],'ICD-9-CM':['410.00','410.01','410.02','410.10','410.11','410.12','410.20','410.21','410.22','410.30','410.31','410.32','410.40','410.41','410.42','410.50','410.51','410.52','410.60','410.61','410.62','410.70','410.71','410.72','410.80','410.81','410.82','410.90','410.91','410.92','412'],'ICD-10-CM':['I21.01','I21.02','I21.09','I21.11','I21.19','I21.21','I21.29','I21.3','I21.4','I22.0','I22.1','I22.2','I22.8','I22.9','I24.1','I25.2']

Diagnostic Study, Performed: Ejection Fraction

'LOINC':['10230-1','18043-0','18044-8','18045-5','18046-3','18047-1','18048-9','18049-7','8806-2','8807-0','8808-8','8809-6','8810-4','8811-2','8812-0']

Encounter, Performed: Care Services in Long-Term Residential Facility

'CPT':['99324','99325','99326','99327','99328','99334','99335','99336','99337']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','27

49

0427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']


'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']

Encounter, Performed: Nursing Facility Visit

'SNOMED-CT':['11797002','12843005','18170008','185316007','185317003','185318008','185320006','185321005','185349003','185463005','185465003','19681004','207195004','270424005','270427003','270430005','308335008','308720009','386473003','390906007','401267002','401271004','406547006','438515009','438516005','439708006','445450000','448337001','4525004','87790002','90526000']


'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']

Encounter, Performed: Outpatient Consultation

'CPT':['99241','99242','99243','99244','99245']

Encounter, Performed: Patient Provider Interaction

'SNOMED-CT':['11797002','12843005','18170008','185316007','185317003','185318008','185320006','185321005','185349003','185463005','185465003','19681004','207195004','270424005','270427003','270430005','308335008','308720009','386473003','390906007','401267002','401271004','406547006','438515009','438516005','439708006','445450000','448337001','4525004','87790002','90526000']

Medication, Active: Beta Blocker Therapy

'RxNorm':['1191185','1297753','1297757','1495058','152916','1593725','197379','197380','197381','197382','197383','198000','198001','198005','198006','198007','198008','198104','198105','198284','198285','198286','199277','199494','199495','199717','199786','199787','200031','200032','200033','245854','245855','310811','387013','686924','751612','751618','827073','854901','854905','854908','854916','854919','856422','856429','856448','856457','856460','856481','856519','856535','856556','856569','856578','856713','856724','856733','860510','860516','860522','860532','866412','866419','866427','866436','866452','866461','866472','866479','866482','866491','866511','866514','866924','896758','896762','896766','896983','896987','904561','904567','904579','904589','904601','978577','978581','998685','998689','998693','998694','998695']

Medication, Active: Beta Blocker Therapy for LVSD

'RxNorm':['200031','200032','200033','686924','854901','854905','854908','854916','854919','860510','860516','860522','860532','866412','866419','866427','866436','866452','866461','866472']

Medication, Allergy: Beta Blocker Therapy Ingredient

'RxNorm':['1007360','10600','1202','1372709','1372756','142130','142132','142144','142146','149','151195','151549','151890','1520','152413','152440','19484','196460','202693','202978','203191','203344','20352','2116','214288','214317','214621','214623','214625','216221','218072','221002','221124','37789','392512','392564','42933','6185','668310','6918','7226','75038','82084','8332','856468','865575','8787','9631']

Medication, Intolerance: Beta Blocker Therapy

'RxNorm':['1191185','1297753','1297757','1495058','152916','1593725','197379','197380','197381','197382','197383','198000','198001','198005','198006','198007','198008','198104','198105','198284','198285','198286','199277','199494','199495','199717','199786','199787','200031','200032','200033','245854','245855','310811','387013','686924','751612','751618','827073','854901','854905','854908','854916','854919','856422','856429','856448','856457','856460','856481','856519','856535','856556','856569','856578','856713','856724','856733','860510','860516','860522','860532','866412','866419','866427','866436','866452','866461','866472','866479','866482','866491','866511','866514','866924','896758','896762','896766','896983','896987','904561','904567','904579','904589','904601','978577','978581','998685','998689','998693','998694','998695']

Medication, Order: Beta Blocker Therapy

'RxNorm':['1191185','1297753','1297757','1495058','152916','1593725','197379','197380','197381','197382','197383','198000','198001','198005','198006','198007','198008','198104','198105','198284','198285','198286','199277','199494','199495','199717','199786','199787','200031','200032','200033','245854','245855','310811','387013','686924','751612','751618','827073','8

50

54901','854905','854908','854916','854919','856422','856429','856448','856457','856460','856481','856519','856535','856556','856569','856578','856713','856724','856733','860510','860516','860522','860532','866412','866419','866427','866436','866452','866461','866472','866479','866482','866491','866511','866514','866924','896758','896762','896766','896983','896987','904561','904567','904579','904589','904601','978577','978581','998685','998689','998693','998694','998695']

Medication, Order: Beta Blocker Therapy for LVSD

'RxNorm':['200031','200032','200033','686924','854901','854905','854908','854916','854919','860510','860516','860522','860532','866412','866419','866427','866436','866452','866461','866472']

Medication, Order: Beta Blocker Therapy Ingredient

'RxNorm':['1007360','10600','1202','1372709','1372756','142130','142132','142144','142146','149','151195','151549','151890','1520','152413','152440','19484','196460','202693','202978','203191','203344','20352','2116','214288','214317','214621','214623','214625','216221','218072','221002','221124','37789','392512','392564','42933','6185','668310','6918','7226','75038','82084','8332','856468','865575','8787','9631']

Medication, Order not done: Medical Reason

'SNOMED-CT':['183932001','183964008','183966005','216952002','266721009','269191009','274512008','31438003','35688006','371133007','397745006','407563006','410534003','410536001','416098002','416406003','428119001','445528004','59037007','62014003','79899007']

Medication, Order not done: Patient Reason

'SNOMED-CT':['105480006','160932005','160934006','182890002','182895007','182897004','182900006','182902003','183944003','183945002','184081006','185479006','185481008','224187001','225928004','266710000','266966009','275694009','275936005','281399006','310343007','373787003','385648002','406149000','408367005','413310006','413311005','413312003','416432009','423656007','424739004','443390004']

Medication, Order not done: System Reason

'SNOMED-CT':['107724000','182856006','182857002','185335007','224194003','224198000','224199008','242990004','266756008','270459005','309017000','309846006','419808006','424553001']

Physical Exam, Performed: Heart Rate

'LOINC':['8867-4']

Procedure, Performed: Cardiac Surgery

SNOMED-CT':['10326007','119564002','119565001','15256002','174911007','175007008','175008003','175009006','175011002','175021005','175022003','175024002','175025001','175026000','175036008','175037004','175038009','175039001','175040004','175041000','175045009','175047001','175048006','175050003','232717009','232719007','232720001','232721002','232722009','232723004','232724005','265481001','275215001','275216000','275227003','275252001','275253006','287277008','30670000','309814006','3546002','359597003','359601003','39202005','39724006','414088005','48431000','74371005','81266008','82247006','90205004'],'CPT':['33140','33510','33511','33512','33513','33514','33516','33517','33518','33519','33521','33522','33523','33533','33534','33535','33536','92920','92924','92928','92933','92937','92941','92943','92980','92981','92982','92984','92995','92996']

Severity: Moderate or Severe 'SNOMED-CT':['24484000','6736007']Patient Characteristic Ethnicity: Ethnicity

'CDC Race':['2135-2','2186-5']



51


'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']



10. Pneumococcal vaccination Status for Older Adults

Source: https://ecqi.healthit.gov/system/files/ecqm/measures/CMS127v5_2.htmleMeasure Title Pneumococcal Vaccination Status for Older Adults



NQF Number 0043 GUID 59657b9b-01bf-4979-a090-8534da1d0516





Description Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine



(c) 2008-2016 National Committee for Quality Assurance. All Rights Reserved.







Stratification None



Rationale Pneumonia is a common cause of illness and death in the elderly and persons with certain underlying conditions such as heart failure, diabetes, cystic fibrosis, asthma, sickle cell anemia, or chronic obstructive pulmonary disease (NHLBI, 2011). In 1998, an estimated 3,400 adults aged > 65 years died as a result of invasive pneumococcal disease (IPD) (CDC, 2003).

Among the 91.5 million US adults aged > 50 years, 29,500 cases of IPD, 502,600 cases of nonbacteremic

52


pneumococcal pneumonia and 25,400 pneumococcal-related deaths are estimated to occur yearly; annual direct and indirect costs are estimated to total $3.7 billion and $1.8 billion, respectively. Pneumococcal disease remains a substantial burden among older US adults, despite increased coverage with 23-valent pneumococcal polysaccharide vaccine, (PPV23) and indirect benefits afforded by PCV7 vaccination of young children (Weycker, et al., 2011).

Vaccination has been found to be effective against bacteremic cases (OR: 0.34; 95% CI: 0.27-0.66) as well as nonbacteremic cases (OR: 0.58; 95% CI: 0.39-0.86). Vaccine effectiveness was highest against bacteremic infections caused by vaccine types (OR: 0.24; 95% CI: 0.09-0.66) (Vila-Corcoles, et al., 2009).


In 2014, the Advisory Committee on Immunization Practices (ACIP) began recommending a dose of 13-valent pneumococcal conjugate vaccine (PCV13) be followed by a dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) 6-12 months later in adults aged 65 and older who have not previously received a pneumococcal vaccination, and in persons over the age of two years who are considered to be at higher risk for pneumococcal disease due to an underlying condition. The two vaccines should not be coadministered and intervals for administration of the two vaccines vary slightly depending on the age, risk group, and history of vaccination (Kobayashi, 2015).

In 2015, ACIP updated its recommendation and changed the interval between PCV13 and PPSV23, from 6-12 months to at least one year for immunocompetent adults aged >=65 years who have not previously received pneumococcal vaccine. For immunocompromised vaccine-naïve adults, the minimum acceptable interval between PCV13 and PPSV23 is 8 weeks. Both immunocompetent and immunocompromised adults aged >=65 years who have previously received a dose of PPSV23 when over the age of 65 should receive a dose of PCV13 at least one year after PPSV23 (>=1 year). Immunocompetent and immunocompromised adults aged >=65 who have previously received a dose of PPSV23 when under the age of 65, should also receive a dose of PCV13 at least one year after PPSV23 (>=1 year) and then another dose of PPSV23 at least one year after PCV13. It is recommended that for those that have this alternative three-dose schedule (2 PPSV23 and 1 PCV13), the three doses should be spread over a time period of five or more years (Kobayashi, 2015).



Reference Kobayashi M, Bennett NM, Gierke R, et al. "Intervals between PCV13 and PPSV23 vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP)." MMWR. (2015);64(34):944-7.

Reference National Heart, Lung and Blood Institute. 2011. "Pneumonia." http://www.nhlbi.nih.gov/health/dci/Diseases/pnu/pnu_whatis.html

Reference Weycker, D., D. Strutton, J. Edelsberg, R. Sato, L.A. Jackson. 2011. "Clinical and Economic Burden of Pneumococcal Disease in Older US Adults." Vaccine 28(31): 4955-60.

Reference Vila-Corcoles, A., E. Salsench, T. Rodriguez-Blanco, O. Ochoa-Gondar, C. de Diego, A. Valdivieso, I. Hospital, F. Gomez-Bertemeu, X. Raga. 2009. "Clinical effectiveness of 23-valent pneumococcal polysaccharide vaccine against pneumonia in middle-aged and older adults: A matched case-control study." Vaccine 27(10):1504-10.

Definition None

Guidance None


Initial Population Patients 65 years of age and older with a visit during the measurement period



None

Numerator Patients who have ever received a pneumococcal vaccination

Numerator Exclusions

Not Applicable


None




o AND: Age>= 65 year(s) at: "Measurement Period"o AND: Union of:

"Encounter, Performed: Office Visit" "Encounter, Performed: Face-to-Face Interaction" "Encounter, Performed: Annual Wellness Visit" "Encounter, Performed: Home Healthcare Services"

53

"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"



Numerator =o AND: Union of:

"Immunization, Administered: Pneumococcal Vaccine" "Procedure, Performed: Pneumococcal Vaccine Administered" "Risk Category Assessment: History of Pneumococcal Vaccine" starts before end of "Measurement Period"





Table 10. Data elements from CMS127v5Data elements CodesEncounter, Performed: Annual Wellness Visit

'HCPCS':['G0438','G0439']


'SNOMED-CT':['12843005','18170008','185349003','185463005','185465003','19681004','207195004','270427003','270430005','308335008','390906007','406547006','439708006','87790002','90526000']


'CPT':['99341','99342','99343','99344','99345','99347','99348','99349','99350']},'

Encounter, Performed: Office Visit 'CPT':['99201','99202','99203','99204','99205','99212','99213','99214','99215']


'CPT':['99395','99396','99397']


'CPT':['99385','99386','99387']

Immunization, Administered: Pneumococcal Vaccine

'CVX':['133','33']

Procedure, Performed: Pneumococcal Vaccine Administered

'SNOMED-CT':['12866006','394678003'],'CPT':['90670','90732']

Risk Category Assessment: History of Pneumococcal Vaccine

'SNOMED-CT':['310578008','473165003']


'CDC Race':['2135-2','2186-5']

Patient Characteristic Payer: Payer 'Source of Payment Typology':['1','11','111','112','113','119','12','121','122','123','129','19','2','21','211','212','213','219','22','23','24','25','29','3','31','311','3111','3112','3113','3114','3115','3116','3119','312','3121','3122','3123','313','32','321','3211','3212','32121','32122','32123','32124','32125','32126','322','3221','3222','3223','3229','33','331','332','333','334','34','341','342','343','349','35','36','361','362','369','37','371','3711','3712','3713','372','379','38','381','3811','3812','3813','3819','382','389','39','4','41','42','43','44','5','51','511','512','513','514','515','519','52','521','522','523','529','53','54','55','59','6','61','611','612','613','619','62','63','64','69','7','71','72','73','79','8','81','82','821','822','823','83','84','85','89','9','91','92','93','94','95','951','

54

953','954','959','96','98','99','9999']Patient Characteristic Race: Race 'CDC Race':['1002-5','2028-9','2054-5','2076-8','2106-3','2131-1']Patient Characteristic Sex: ONC Administrative Sex


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Documents

informatics.gpcnetwork.org€¦ · Web view01/08/2017 · ['E10.10','E10.11','E10.21','E10.22','E10.29','E10.311','E10.319','E10.321','E10.329','E10.331','E10.339','E10.341','E10.349','E10.351','E10.359','E10.36','E10.39