CMS165v4

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Done
    • Priority: Moderate
    • Component/s: Measure
    • None
    • Elissa Chandler
    • 2677255354
    • NextGen
    • Hide
      Example 1:

      There are two 'Adult outpatient visits':
      1.On September 20, 2015 with two qualifying BP readings (139/89)
      2.On December 12, 2015 with no BP readings
      The measure is interested in the most recent visit with BP readings. Therefore, the visit on September 20 will count as 'Occurrence A' of the visit and satisfy numerator criteria.
       
      Example 2:
      You are correct. The visit where BP results were documented as 139/90 is not a qualifying encounter (due to the invalid CPT code). Therefore, the patient will not meet numerator criteria.
       
      Example 3:
      You are correct. The results during the most recent visit were greater than 140/90. Therefore, the blood pressure is not adequately controlled and the patient fails to meet numerator criteria.
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      Example 1: There are two 'Adult outpatient visits': 1.On September 20, 2015 with two qualifying BP readings (139/89) 2.On December 12, 2015 with no BP readings The measure is interested in the most recent visit with BP readings. Therefore, the visit on September 20 will count as 'Occurrence A' of the visit and satisfy numerator criteria.   Example 2: You are correct. The visit where BP results were documented as 139/90 is not a qualifying encounter (due to the invalid CPT code). Therefore, the patient will not meet numerator criteria.   Example 3: You are correct. The results during the most recent visit were greater than 140/90. Therefore, the blood pressure is not adequately controlled and the patient fails to meet numerator criteria.
    • CMS165v4/NQF0018
    • high impacts development

      The numerator criteria from the measure spec is stated:

      Numerator =
      AND: Most Recent:
      "Occurrence A of Encounter, Performed: Adult Outpatient Visit" satisfies all:
      overlaps "Occurrence A of Diagnosis: Essential Hypertension"
      during "Measurement Period"
      overlaps "Physical Exam, Performed: Diastolic Blood Pressure (result)"
      overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)"
      AND: "Physical Exam, Performed: Diastolic Blood Pressure" satisfies all:
      Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit"
      (result < 90 mmHg)
      AND: "Physical Exam, Performed: Systolic Blood Pressure" satisfies all:
      Most Recent: during "Occurrence A of Encounter, Performed: Adult Outpatient Visit"
      (result < 140 mmHg)

      "
      Based on the numerator criteria stated above from CMS165v4 specification in regards to the numerator, BP < 140/90 must be documented DURING the MOST RECENT Adult Outpatient Visit to be included in the numerator. Hence, if there was either ‘No BP documented OR BP is >= 140/90’ DURING the MOST RECENT Adult Outpatient Visit the patient would NOT be included in the numerator.

      There has been a lot of confusion with various interpretation of the numerator and which BP on which encounter is considered in order to comply with the measure requirement. We provided several examples below to ensure we have the logic accurately reflected to align with the intent of the measure. Please review and provide your feedback.

      Thank you

      Provided the measurement period is 2015, can you verify if the example patients will meet numerator?

      Example 1
      On September 20, 2015 patient has documented
      Encounter visit, CPT 99201
      active diagnosis of hypertension,
      BP results 139/89.
      On December 12, 2015, patient has documented
      Encounter visit, CPT 99202
      Active diagnosis of hypertension
      No BP results was documented on this encounter.

      Based on the measure specification this patient would NOT met numerator as they do NOT have a BP documented DURING the most recent Adult Outpatient Visit on 12/12/15.

      Please confirm if this patient will meet numerator?

      Example 2
      On September 11, 2015, patient has documented
      Encounter visit, CPT 99201
      active diagnosis of hypertension,
      BP results 141/90.
      On December 20, 2015, patient has documented
      INVAILD CPT encounter code (example dialysis encounter CPT)
      an active diagnosis of hypertension
      BP results 139/89

      Based on the measure specification this patient would NOT met numerator as they do NOT have a BP < 149/90 documented DURING the most recent Adult Outpatient Visit. The BP 139/89 on 12/20/15 would NOT be considered for numerator as it was NOT documented on a qualifying Adult Outpatient Visit.

      Please confirm if this patient will meet numerator?

      Example 3
      On January 1, 2015, patient has documented
      Encounter visit, CPT 99201
      active diagnosis of hypertension
      BP results 139/89
      On March 1, 2015, patient has documented
      Encounter visit, CPT 99202
      active diagnosis of hypertension
      BP results 150/90

      Based on the measure specification this patient would NOT met numerator as they do NOT have a BP < 149/90 documented DURING the most recent Adult Outpatient Visit on 3/1/15.

      Please confirm if this patient will meet numerator?

            Assignee:
            Mathematica EC eCQM Team (Inactive)
            Reporter:
            Elissa Chandler (Inactive)
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              Created:
              Updated:
              Resolved:
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