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  2. CQM-7011

Counting IPP from another system

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
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      Hello and thank you for the question regarding CMS138v12 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention.

      Under a shared EHR, patients associated with the eligible clinicians in your organization will be counted in the measure, irrespective of whether they received care in the inpatient or ambulatory setting. Because CMS138v12 contains inpatient codes, patients will be included in the Initial Population who have at least two Qualifying Visits during the measurement period or one Preventive Visit.

      Preventive Visit During Measurement Period

      valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240)
      valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025)
      valueset "Preventive Care Services Group Counseling" (2.16.840.1.113883.3.464.1003.101.12.1027)
      code "Unlisted preventive medicine service" ("CPT Code (99429)")
      valueset "Preventive Care Services Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026)
      code "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure" ("CPT Code (99024)")
      valueset "Nutrition Services" (2.16.840.1.113883.3.464.1003.1006)
      valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)
       
      Qualifying Visit During Measurement Period

      code "Health behavior intervention, individual, face-to-face; initial 30 minutes" ("CPT Code (96158)")
      code "Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)" ("CPT Code (96156)")
      valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016)
      valueset "Occupational Therapy Evaluation" (2.16.840.1.113883.3.526.3.1011)
      valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
      valueset "Ophthalmological Services" (2.16.840.1.113883.3.526.3.1285)
      valueset "Physical Therapy Evaluation" (2.16.840.1.113883.3.526.3.1022)
      valueset "Psych Visit Diagnostic Evaluation" (2.16.840.1.113883.3.526.3.1492)
      valueset "Psych Visit Psychotherapy" (2.16.840.1.113883.3.526.3.1496)
      valueset "Psychoanalysis" (2.16.840.1.113883.3.526.3.1141)
      valueset "Speech and Hearing Evaluation" (2.16.840.1.113883.3.526.3.1530)
      valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)
      valueset "Online Assessments" (2.16.840.1.113883.3.464.1003.101.12.1089)
       
      Value sets can be found on The National Library of Medicine's Value Set Authority

      Center (VSAC), https://vsac.nlm.nih.gov/. The VSAC provides downloadable access to all official versions of value sets content contained in the eCQM specifications. We hope this helps.
      Show
      Hello and thank you for the question regarding CMS138v12 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. Under a shared EHR, patients associated with the eligible clinicians in your organization will be counted in the measure, irrespective of whether they received care in the inpatient or ambulatory setting. Because CMS138v12 contains inpatient codes, patients will be included in the Initial Population who have at least two Qualifying Visits during the measurement period or one Preventive Visit. Preventive Visit During Measurement Period valueset "Annual Wellness Visit" (2.16.840.1.113883.3.526.3.1240) valueset "Preventive Care Services Established Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1025) valueset "Preventive Care Services Group Counseling" (2.16.840.1.113883.3.464.1003.101.12.1027) code "Unlisted preventive medicine service" ("CPT Code (99429)") valueset "Preventive Care Services Individual Counseling" (2.16.840.1.113883.3.464.1003.101.12.1026) code "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure" ("CPT Code (99024)") valueset "Nutrition Services" (2.16.840.1.113883.3.464.1003.1006) valueset "Preventive Care Services Initial Office Visit, 18 and Up" (2.16.840.1.113883.3.464.1003.101.12.1023)   Qualifying Visit During Measurement Period code "Health behavior intervention, individual, face-to-face; initial 30 minutes" ("CPT Code (96158)") code "Health behavior assessment, or re-assessment (ie, health-focused clinical interview, behavioral observations, clinical decision making)" ("CPT Code (96156)") valueset "Home Healthcare Services" (2.16.840.1.113883.3.464.1003.101.12.1016) valueset "Occupational Therapy Evaluation" (2.16.840.1.113883.3.526.3.1011) valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001) valueset "Ophthalmological Services" (2.16.840.1.113883.3.526.3.1285) valueset "Physical Therapy Evaluation" (2.16.840.1.113883.3.526.3.1022) valueset "Psych Visit Diagnostic Evaluation" (2.16.840.1.113883.3.526.3.1492) valueset "Psych Visit Psychotherapy" (2.16.840.1.113883.3.526.3.1496) valueset "Psychoanalysis" (2.16.840.1.113883.3.526.3.1141) valueset "Speech and Hearing Evaluation" (2.16.840.1.113883.3.526.3.1530) valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080) valueset "Online Assessments" (2.16.840.1.113883.3.464.1003.101.12.1089)   Value sets can be found on The National Library of Medicine's Value Set Authority Center (VSAC), https://vsac.nlm.nih.gov/ . The VSAC provides downloadable access to all official versions of value sets content contained in the eCQM specifications. We hope this helps.
    • CMS0138v12
    • We have no way of working IPP from a system that is not ours.

      We pay a hospital for the use of the ambulatory side of their EHR. Our surgeons also perform surgeries and hospital rounding on the hospital's in-patient system as they do at other hospitals in the area. 

      The hospital is counting the in-patient encounters of our EC's on their system in our measures. Specifically eCQM CMS-138 Tobacco Screening and Cessation. We do not report together. Other than our providers, our staff do not have access to the in-patient side of the system. We have no way to perform the workflow to meet the numerator as it is not in our ambulatory system. We are not expected to this for other hospitals our EC's see patients.

      Is it correct for the hospital to count the in-patient encounters in our IPP?

      Thank You,

      Rebecca

       

            edave Mathematica EC eCQM Team
            acsbecca Arizona Community Specialists (Inactive)
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