Brief Description of Measure:

CMS117: Childhood Immunization Status

CMS122: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) 

CMS124: Cervical Cancer Screening

CMS125: Breast Cancer Screening

CMS127: Pneumococcal Vaccination Status for Older Adults

CMS128: Anti-depressant Medication Management

CMS130: Colorectal Cancer Screening

CMS131: Diabetes: Eye Exam

CMS134: Diabetes: Medical Attention for Nephropathy

CMS136: Follow-Up Care for Children Prescribed ADHD Medication (ADD)

CMS137: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

CMS139: Falls: Screening for Future Fall Risk

CMS146: Appropriate Testing for Pharyngitis

CMS153: Chlamydia Screening for Women

CMS154: Appropriate Treatment for Upper Respiratory Infection (URI)

CMS155: Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

CMS156: Use of High-Risk Medications in Older Adults

CMS165: Controlling High Blood Pressure

CMS56: Functional Status Assessment for Total Hip Replacement

CMS66: Functional Status for Total Knee Replacement

CMS74: Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists

CMS75: Children Who Have Dental Decay or Cavities

CMS90: Functional Status Assessments for Heart Failure

Description of Issue:
​A JIRA ticket from 3/11/2020 (CQM-3946) indicated that it is likely many eligible clinicians will not be the provider to order or provide hospice or palliative care; therefore, the measure logic should enable eligible clinicians to assess and document that their patients are currently receiving hospice or palliative care.

A logic review comment from AU2021 noted that the current specification will not capture hospice status noted on a problem list and recommended adding diagnosis datatype with a value set for SNOMED-CT hospice codes covering hospice status and transitions since EHRs do not have consistent documentation patterns.

Proposed Solution:

​Given the recommendations from the implementer and standards team, we would like to propose adding hospice "assessment" criteria and new hospice "encounter" criteria, as well as expanding existing value sets with additional codes. Below are proposed changes to the hospice exclusion used in the indicated measures:

(1) Add a QDM datatype "Assessment, Performed" with code attribute requiring LOINC 45755-6 and result requiring SNOMED-CT code "Yes (qualifier value).

• 45755-6, LOINC, Hospice care [Minimum Data Set]
• 373066001, SNOMED-CT, Yes (qualifier value)

(2) Update existing grouping value set "Hospice Care Ambulatory" (OID: 2.16.840.1.113883.3.526.3.1584) with the following changes. Note that the current logic uses an extensional value set (OID: 2.16.840.1.113762.1.4.1108.15) and will be updated to using the grouping value set (OID: 2.16.840.1.113883.3.526.3.1584).
Add the following SNOMED-CT finding codes to the existing extensional value set "Hospice Care Ambulatory" (OID: 2.16.840.1.113762.1.4.1108.15):

• 170935008, Full care by hospice (finding)
• 170936009, Shared care - hospice and general practitioner (finding)

Add the following CPT codes to a new extensional value set, "Hospice Care Ambulatory" (OID: 2.16.840.1.113883.3.464.1003.1007):

• 99377, CPT, Supervision of a hospice patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (e.g., legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes
• 99378, CPT, ...30 minutes or more

Add the following HCPCS code to a new extensional value set, "Hospice Care Ambulatory" (OID: 2.16.840.1.113883.3.464.1003.1008):

• G0182, HCPCS, Physician supervision of a patient under a Medicare-approved hospice (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in the patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month, 30 minutes or more (G0182)

(3) Create a new value set grouping called “Hospice Encounter” (2.16.840.1.113883.3.464.1003.1003), which will contain the following two extensional value sets. This value set will be required with QDM datatype "Encounter, Performed".

Add the following HCPCS codes to a new extensional value set, "Hospice Encounter" (OID: 2.16.840.1.113883.3.464.1003.1001):

• G9473, Services performed by chaplain in the hospice setting, each 15 minutes (G9473))
• G9474, Services performed by dietary counselor in the hospice setting, each 15 minutes (G9474)
• G9475, Services performed by other counselor in the hospice setting, each 15 minutes (G9475)
• G9476, Services performed by volunteer in the hospice setting, each 15 minutes (G9476)
• G9477, Services performed by care coordinator in the hospice setting, each 15 minutes (G9477)
• G9478, Services performed by other qualified therapist in the hospice setting, each 15 minutes (G9478)
• G9479, Services performed by qualified pharmacist in the hospice setting, each 15 minutes (G9479)
• Q5003, Hospice care provided in nursing long term care facility (ltc) or non-skilled nursing facility (nf) (Q5003)
• Q5004, Hospice care provided in skilled nursing facility (snf) (Q5004)
• Q5005, Hospice care provided in inpatient hospital (Q5005)
• Q5006, Hospice care provided in inpatient hospice facility (Q5006)
• Q5007, Hospice care provided in long term care facility (Q5007)
• Q5008, Hospice care provided in inpatient psychiatric facility (Q5008)
• Q5010, Hospice home care provided in a hospice facility (Q5010)
• S9126, Hospice care, in the home, per diem (S9126)
• T2042, Hospice routine home care; per diem (T2042)
• T2043, Hospice continuous home care; per hour (T2043)
• T2044, Hospice inpatient respite care; per diem (T2044)
• T2045, Hospice general inpatient care; per diem (T2045)
• T2046, Hospice long term care, room and board only; per diem (T2046)

Add the following SNOMED codes to a new extensional value set, "Hospice Encounter" (OID: 2.16.840.1.113883.3.464.1003.1002):

• 183919006, Urgent admission to hospice (procedure)
• 183920000, Routine admission to hospice (procedure)
• 183921001, Admission to hospice for respite (procedure)
• 305336008, Admission to hospice (procedure)

The exclusion logic will be updated as such:

CURRENT SPECIFICATION:
//Terminology
code system "SNOMEDCT": 'urn:oid:2.16.840.1.113883.6.96'
value set "Encounter Inpatient": 'urn:oid:2.16.840.1.113883.3.666.5.307'
value set "Hospice care ambulatory": 'urn:oid:2.16.840.1.113762.1.4.1108.15'
code "Discharge to healthcare facility for hospice care (procedure)": '428371000124100' from "SNOMEDCT" display 'Discharge to healthcare facility for hospice care (procedure)'
code "Discharge to home for hospice care (procedure)": '428361000124107' from "SNOMEDCT" display 'Discharge to home for hospice care (procedure)'

//Logic
define "Has Hospice":
exists ( ["Encounter, Performed": "Encounter Inpatient"] DischargeHospice
where ( DischargeHospice.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
or DischargeHospice.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" )
and DischargeHospice.relevantPeriod ends during "Measurement Period" )
or exists ( ["Intervention, Order": "Hospice care ambulatory"] HospiceOrder
where HospiceOrder.authorDatetime during "Measurement Period" )
or exists ( ["Intervention, Performed": "Hospice care ambulatory"] HospicePerformed
where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period" )

PROPOSED SPECIFICATION:
//Terminology
code system "SNOMEDCT": 'urn:oid:2.16.840.1.113883.6.96'
code system "LOINC": 'urn:oid:2.16.840.1.113883.6.1'
value set "Encounter Inpatient": 'urn:oid:2.16.840.1.113883.3.666.5.307'
value set "Hospice Encounter": 'urn:oid:2.16.840.1.113883.3.464.1003.1003'
value set "Hospice Care Ambulatory": 'urn:oid:2.16.840.1.113883.3.526.3.1584'
code "Discharge to healthcare facility for hospice care (procedure)": '428371000124100' from "SNOMEDCT" display 'Discharge to healthcare facility for hospice care (procedure)'
code "Discharge to home for hospice care (procedure)": '428361000124107' from "SNOMEDCT" display 'Discharge to home for hospice care (procedure)'
code "Hospice care [Minimum Data Set]": '45755-6' from "LOINC" display 'Hospice care [Minimum Data Set]'
code "Yes (qualifier value)": '373066001' from "SNOMEDCT" display 'Yes (qualifier value)'

//Logic
define "Has Hospice":
exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)" )
and InpatientEncounter.relevantPeriod ends during day of "Measurement Period" )
or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
where HospiceEncounter.relevantPeriod overlaps "Measurement Period" )
or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
where HospiceAssessment.result ~ "Yes (qualifier value)"
and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps "Measurement Period" )
or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
where HospiceOrder.authorDatetime during day of "Measurement Period" )
or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period" )

Rationale for Change:

This change will address the concerns expressed by the implementers and improve feasibility of the hospice care exclusion specification.