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MIPS CQM

2024 Measure Specifications

Quality ID #001 (DM-2)
Diabetes: Hemoglobin A1c (HbA1c)Poor Control (>9%)

Measure Description

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

Denominator

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

    Denominator Note: 

    To assess the age for exclusions, the patient’s age on the date of the encounter should be used.

             

    Denominator Criteria:

    Patients 18 through 75 years of age on date of encounter

    AND

    Diagnosis for Diabetes: See PDF below for full list of ICD-10-CM codes.

    AND

    Patient Encounter during performance period (CPT or HCPCS): 

    97802, 97803, 97804, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348,              99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0270, G0271, G0438, G0439

    (*Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS).           These non-covered services should be counted in the denominator population for MIPS CQMs.)

    AND NOT

    Denominator Exclusions

             Hospice services provided to patient any time during the measurement period: (G9687)

             or

             Palliative care services provided to patient any time during the measurement period: (G9988)

             or

            Patients age 66 and older in Institutional Special Needs Plans (SNP) or residing in long-term care with a POS code 32, 33, 34,              54 or 56 for more than 90 consecutive days during the measurement period: (G2081)

            or

            Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND a                            dispensed medication for dementia during the measurement period or the year prior to the measurement period: (G2090)

            or

            Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period AND either                  one acute inpatient encounter with a diagnosis of advanced illness or two outpatient, observation, ED or nonacute inpatient                encounters on different dates of service with an advanced illness diagnosis during the measurement period or the year prior                to the measurement period: (G2091)

                  Dementia Exclusion Medications:

                  Cholinesterase inhibitors - Donepezil, Rivastigmine, Galantamine

                  Miscellaneous central nervous system agents - Memantine

                  Dementia Combinations - Donepezil-memantine

          

             Denominator Exceptions

             None

Numerator

Patients whose most recent HbA1c level (performed during the measurement period) is >9.0% or is missing or was not performed during the measurement period.

Numerator Instructions

Inverse MeasureA lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures, a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

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. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance. Do not include HbA1c levels reported by the patient.

Numerator Options:

 Performance Met: Most recent hemoglobin A1c level >9.0% (M1211)

OR

 Performance Met: Hemoglobin A1c level is missing, or was not performed during the measurement period (12 months) (M1212)

OR

Performance Not Met: Most recent hemoglobin A1c (HbA1c) level <7.0% (3044F)

OR

Performance Not Met: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% (3051F)

OR

Performance Not Met: Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% (3052F)

Instructions

This measure is to be submitted a minimum of once per performance period for patients with diabetes seen during the performance period. The most recent quality data code submitted will be used for performance calculation. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable.

Quality ID #236 (HTN-2)
Controlling High Blood Pressure

Measure Description

Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during the measurement period. 

Denominator

Patients 18-85 years of age who had a visit during the measurement period and a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period.

     Denominator Note: The diagnosis of essential hypertension must be present some time between 1 year prior to the                     measurement period and the first six months of the measurement period (January 1,2023 - June 30, 2024).

     To assess the age for exclusions, the patient's age on the date of the encounter should be used.

     Denominator Criteria:

     Patients 18 to 85 years of age on date of encounter

     AND

     Diagnosis for hypertension (ICD-10-CM): I10

     AND

     Patient encounter during performance period (CPT or HCPCS): : 98980, 99202, 99203, 99204, 99205, 99212, 99213, 99214,           99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, 99421,               99422, 99423, 99457, G0438, G0439, G2250, G2251, G2252

     (*Signifies that this CPT category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS).           These non-covered services should be counter in the denominator population for MIPS CQMs.)

     AND NOT

              Denominator Exclusions:

              Hospice services given to patient any time during the measurement period: (G9740)

              or

             Palliative care services given to patient any time during the measurement period: (G0031)

              or

             Documentation of end stage renal disease (ESRD), dialysis, renal transplant before or during the measurement period or                     pregnancy during the measurement period: (G9231) 

              or

              Patients age 66 or older in Institutional Special Needs Plans (SNP) or residing in long-term care with POS code 32, 33, 34,                    54, or 56 for more than 90 consecutive days during the measurement period: (G9910)

              or

              Patients 66 - 80 years of age with at least one claim/encounter for frailty during the measurement period AND a dispensed                  medication for dementia during the measurement period or the year prior to the measurement period: (G2115)

              or

              Patients 66 - 80 years of age with at least one claim/encounter for frailty during the measurement period AND either one                      acute inpatient encounter with a diagnosis of advanced illness or two outpatient, observation, ED or nonacute inpatient                      encounters on different dates of service with an advanced illness diagnosis during the measurement period or the year prior                to the measurement period: (G2116)

              or

              Patients 81 years of age and older with at least one claim/encounter for frailty during the measurement period: (G2118)

                    

              Dementia Exclusion Medications

                    Cholinesterase inhibitors - Donepezil, Rivastigmine, Galantamine

                    Miscellaneous central nervous system agents - Memantine

                    Dementia combinations - Donepezil-memantine

               Denominator Exceptions

                    None

Numerator

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) during the measurement period. 

Numerator Instructions:

To describe both systolic and diastolic blood pressure values, each must be submitted separately. If there are multiple blood pressures on the same date of service, use the lowest systolic and lowest diastolic blood pressure on that date as the representative blood pressure.

Numerator Note:

In reference to the numerator element, only blood pressure readings performed by a clinician or an automated blood pressure monitor or device are acceptable for numerator compliance with this measure. This includes blood pressures taken in person by a clinician and blood pressures measured remotely by electronic monitoring devices capable of transmitting the blood pressure data to the clinician. Blood pressure readings taken by an automated blood pressure monitor or device and conveyed by the patient to the clinician are also acceptable. It is the clinician’s responsibility and discretion to confirm the automated blood pressure monitor or device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient’s medical record.

Do not include BP readings: 

  • Taken during an acute inpatient stay or an ED visit

  • Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests. BP readings taken on the same day that the member receives a common low-intensity or preventive procedure are eligible for use. For example, the following procedures are considered common low intensity or preventive (this list is just for reference and is not exhaustive): Vaccinations, Injections (e.g., allergy, vitamin B-12, insulin, steroid, Toradol, Depo-Provera, testosterone, lidocaine), TB Test, IUD insertion, eye exam with dilating agents, wart or mole removal.

  • Taken by the patient using a non-digital device such as with a manual blood pressure cuff and a stethoscope.

If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."

If there are multiple blood pressure readings on the same day, use the lowest systolic and  the lowest diastolic reading as the most recent blood pressure reading. Ranges and thresholds do not meet criteria for this measure. A distinct numeric  result for both the systolic and diastolic BP reading is required for numerator compliance.

Numerator Options:

 Performance Met: Most recent systolic blood pressure <140 mmHg (G8752)

OR

Performance Not Met: Most recent systolic blood pressure >140 mmHg (G8753)

AND

Performance Met: Most recent diastolic blood pressure <90 mmHg (G8754)

OR

Performance Not Met: Most recent diastolic blood pressure >90 mmHg (G8755)

OR

Performance Not Met: No documentation of blood pressure measurement, reason not given (G8756)

Instructions

This measure is to be submitted a minimum of once per performance period for patients with hypertension seen during the performance period. The performance period for this measure is 12 months. The most recent quality code submitted will be used for performance calculation. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Quality ID #001 (DM-2)
Quality ID #236 (HTN-2)

Quality ID #134 (PREV-12)
Preventive Care and Screening for Depression and Follow-up Plan

Measure Description

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter.

Denominator

All patients aged 12 years and older at the beginning of the measurement period with at least one qualifying encounter during the measurement period.

     Denominator Note: The intent of the measure is to screen for depression in patients who have never had a diagnosis of               bipolar disorder prior to the eligible encounter used to evaluate the numerator. Patients who have been diagnosed with             bipolar disorder will be excluded from the measure.

     Denominator Criteria:

     Patients aged >12 years of age at the beginning of the performance period

AND

     Patient encounter during the performance period (CPT or HCPCS): 

     59400, 59510, 59610, 59618, 90791, 90792, 90832, 90834, 90837, 92622, 92625, 96105, 96110*, 96112, 96116, 96125, 96136,           96138, 96156, 96158, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97802, 97803, 98966, 98967, 98968, 99078, 99202,             99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341,             99342, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99424, 99441, 99442, 99443, 99483, 99484, 99491,         99492, 99493, 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, G0101, G0270, G0271, G0402, G0438, G0439,       G0444

     *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS).             These non-covered services should be counted in the denominator population for MIPS CQMs.   

AND NOT

               Denominator Exclusions:

               Documentation stating the patient has had a diagnosis of bipolar disorder: (G9717)

               Denominator Exceptions:

               Patient Reason(s): Patient refuses to participate in or complete the depression screening

               OR

               Medical Reason(s): Documentation of medical reason for not screening patient for depression (e.g., cognitive, functional, or                 motivational limitations that may impact accuracy of results; patient is in an urgent or emergent situation where time is of                     the essence and to delay treatment would jeopardize the patient's health status.)

Numerator

Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter

Definitions

Screening: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.

Standardized Depression Screening Tool - A normalized and validated depression screening tool developed for the patient population in which it is being utilized.

Examples of standardized depression screening tools include but are not limited to:

  • Adolescent Screening Tools (12-17 years)

    • Patient Health Questionnaire for Adolescents (PHQ-A)

    • Beck Depression Inventory-Primary Care Version (BDI-PC)

    • Mood Feeling Questionnaire (MFQ)

    • Center for Epidemiologic Studies Depression Scale (CES-D)

    • Patient Health Questionnaire (PHQ-9)

    • Pediatric Symptom Checklist (PSC-17)

    • Prime MD-PHQ-2

  • Adult Screening Tools (18 years and older)

    • Patient Health Questionnaire (PHQ-9)

    • Beck Depression Inventory (BDI or BDI-II)

    • Center for Epidemiologic Studies Depression Scale (CES-D)

    • Depression Scale (DEPS)

    • Duke Anxiety-Depression Scale (DADS)

    • Geriatric Depression Scale (GDS)

    • Cornell Scale for Depression in Dementia (CSDD)

    • Prime MD-PHQ-2

    • Hamilton Rating Scale for Depression (HAM-D)

    • Quick Inventory of Depressive Symptomatology Self-Report (QID-SR)

    • Computerized Adaptive Testing Depression Inventory (CAT-DI)

    • Computerized Adaptive Diagnostic Screener (CAD-MDD)

  • Perinatal Screening Tools

    • Edinburgh Postnatal Depression Scale

    • Postpartum Depression Screening Scale

    • Patient Health Questionnaire 9 (PHQ-9)

    • Beck Depression Inventory

    • Beck Depression Inventory -II

    • Center for Epidemiologic Studies Depression Scale

    • Zung Self-rating Depression Scale

Follow-up Plan - Documented follow-up for a positive depression screening must include one or more of the following:

  • Referral to a clinician for additional evaluation and assessment to formulate a follow-up plan for a positive depression screen

  • Pharmacological interventions

  • Other interventions or follow-up for the diagnosis or treatment of depression

Examples of a follow-up plan include but are not limited to:

  • Referral to a provider or program for further evaluation for depression, for example, referral to a psychiatrist, psychiatric nurse practitioner, psychologist, clinical social worker, mental health counselor, or other mental health service such as family or group therapy, support group, depression management program, or other service for treatment of depression.

  • Other interventions designed to treat depression such as behavioral health evaluation psychotherapy, pharmacological interventions, or additional treatment options.

Numerator Instructions:

A depression screen is completed on the date of the encounter or up to 14 calendar days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan must be documented on the date of or up to two calendar days after the date of the encounter, such as referral to a provider for additional evaluation, pharmacological interventions, or other interventions for the treatment of depression. An example to illustrate the follow-up plan documentation timing: if the encounter is on a Monday from 3-4 pm (day 0) and the patient screens positive, the clinician has through anytime on Wednesday (day 2) to complete follow-up plan documentation.

 

This is a patient-based measure. Depression screening is required once per measurement period, not at all encounters. An age-appropriate, standardized, and validated depression screening tool must be used for numerator compliance. The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression. The depression screening must be reviewed and addressed by the provider on the date of the encounter. Positive pre-screening results indicating a patient is at high risk for self-harm should receive more urgent intervention as determined by the provider practice. The screening should occur during a qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter.

 

The measure assesses the most recent depression screening completed either during the qualifying encounter or within the 14 calendar days prior to that encounter. Therefore, a clinician would not be able to complete another screening at the time of the encounter to count towards a follow-up, because that would serve as the most recent screening. In order to satisfy the follow-up requirement for a patient screening positively, the eligible clinician would need to provide one of the aforementioned follow-up actions, which does not include use of a standardized depression screening tool.

The follow-up plan MUST still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician or provider’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.

Should a patient screen positive for depression, a clinician should:

  • Only order pharmacological intervention when appropriate and after sufficient diagnostic evaluation. However, for the purposes of this measure, additional screening and assessment during the qualifying encounter will not qualify as a follow-up plan.

  • Opt to complete a suicide risk assessment when appropriate and based on individual patient characteristics. However, for the purposes of this measure, a suicide risk assessment or additional screening using a standardized tool, will not qualify as a follow-up plan.

Numerator Options:

Performance Met: Screening for depression is documented as being positive AND a follow-up plan is documented (G8431)

OR

Performance Met: Screening for depression is documented as negative, a follow-up plan is not required (G8510)

OR

Denominator Exception: Screening for depression not completed, documented patient or medical reason (G8433)

OR

Performance Not Met: Depression screening not documented, reason not given (G8432)

OR

Performance Not Met: Screening for depression documented as positive, follow-up plan not documented, reason not given (G8511)

Instructions

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. The most recent screening submitted will be used for performance calculation. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The follow-up plan must be related to a positive depression screening, example: “Patient referred for psychiatric evaluation due to positive depression screening.”

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) are allowable

Quality ID #134 (PREV-12)
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