ACO - CMS Web Interface (APP)
2024 Measure Specifications
The CMS Web Interface lets groups, virtual groups, and APM entities of 25 or more eligible clinicians securely submit over the internet.
ACO-13 (Care-2)
Falls: Screening for Future Fall Risk
Measure Description
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.
Denominator
Patients aged 65 years and older at the start of the measurement period with a visit during the measurement period.
Denominator Exclusions: None
Denominator Exceptions: None
​
Numerator
Patients who were screened for future fall risk at least once within the measurement period.
Definitions
Screening for Future Fall Risk: Documented assessment of whether an individual has experienced a fall or problems with gait or balance. A specific screening tool is not required for this measure, however potential screening tools include the Morse Fall Scale and the timed Get-Up-And-Go test.
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Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
CPT II 3288F - Falls risk assessment documented (GER)
CPT II 1100F - Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER).
CPT II 1101F - Patient screened for future fall risk; documentation of 2 or more falls in the past year or any fall with injury in the past year (GER).
ACO-27 (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 Exclusions:
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.
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.
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.
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.
​
Guidance
Patient is numerator compliant if most recent HbA1c level is >9.0%, the most recent HbA1c result is missing, or if there are no HbA1c tests performed and results documented during the measurement period. Do not include HbA1c levels reported by the patient. If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance. Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for numerator compliance.
2024 Changes
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Denominator Exclusion(s):
For 2024 Dementia combination Donepezil-memantine is added to the dementia medication exclusion list.
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
CPT II 3044F- Most recent hemoglobin A1c (HbA1c) level less than 7.0% (DM)
CPT II 3051F - Most recent hemoglobin A1c (HbA1c) level greater than or equal to 7.0% and less than 8.0% (DM)
CPT II 3052F - Most recent hemoglobin A1c (HbA1c) level greater than or equal to 8.0% and less than or equal to 9.0% (DM)
CPT II 3046F - Most recent hemoglobin A1c level greater than 9.0% (DM)
CPT4 83036 - Hemoglobin; Glycosylated (A1c)
CTP4 83037 - Hemoglobin; glycosylated (A1c) by device cleared by FDA for home use
ACO-28 (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 and a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period.
Denominator Exclusions:
Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period. Also exclude patients with a diagnosis of pregnancy during the measurement period.
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.
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.
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.
or
Patients 81 years of age and older with at least one claim/encounter for frailty during the measurement period.
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.
Guidance
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
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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.
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Taken by the patient using a non-digital device such as with a manual blood pressure cuff and a stethoscope.
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If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."
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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.
2024 Changes
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Denominator Exclusion(s):
For 2024 Dementia combination Donepezil-memantine is added to the dementia medication exclusion list.
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
CPT II 3078F - Most recent diastolic blood pressure less than 80 mm Hg (HTN, CKD, CAD) (DM)
CPT II 3079F - Most recent diastolic blood pressure 80-89 mm Hg (HTN, CKD, CAD) (DM)
CPT II 3080F -Most recent diastolic blood pressure greater than or equal to 90 mm Hg (HTN, CKD, CAD) (DM)
CPT II 3074F - Most recent systolic blood pressure less than 130 mm Hg (DM) (HTN, CKD, CAD)
CPT II 3075F - Most recent systolic blood pressure 130-139 mm Hg (DM) (HTN, CKD, CAD)
CPT II 3077F - Most recent systolic blood pressure greater than or equal to 140 mm Hg (HTN, CKD, CAD) (DM)
HCPCS G8752 - Most recent systolic blood pressure < 140 mmhg
HCPCS G8753 - Most recent systolic blood pressure >= 140 mmhg
HCPCS G8754 - Most recent diastolic blood pressure < 90 mmhg
HCPCS G8755 - Most recent diastolic blood pressure >= 90 mmhg
ACO-40 (MH-1)
Depression Remission at 12 Months
Measure Description
The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.
Denominator
Adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with a diagnosis of major depression or dysthymia and an initial Patient Health Questionnaire-9 item version (PHQ-9) or Patient Health Questionnaire-9 Modified for Teens and Adolescents (PHQ-9M) score greater than nine during the index event. Patients may be assessed using PHQ-9 or PHQ-9M on the same date or up to 7 days prior to the encounter (index event).
Denominator Exclusions:
-
Patients with an active diagnosis of bipolar disorder any time prior to the end of the measurement assessment period
-
Patients with an active diagnosis of select personality disorders (select types; cyclothymic, borderline, histrionic and factitious), any time prior to the end of the measure assessment period
-
Patients with an active diagnosis of schizophrenia or psychotic disorder any time prior to the end of the measure assessment period
-
Patients with aa active diagnosis of pervasive developmental disorder any time prior to the end of the measure assessment period
-
Patients with an active diagnosis of personality disorder emotionally labile any time prior to the end of the measure assessment period
Denominator Exceptions:
None
​
Numerator
Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five.
Definition
Denominator Identification Period: The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. The denominator identification period is from 11/1/2022 to 10/31/2023. For patients with an index event, there needs to be enough time following the index for the patients to have the opportunity to reach remission twelve months +/- 60 days after the index event.
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Index Event Date: The date in which the first instance of elevated PHQ-9 or PHQ-9M greater than nine AND diagnosis of depression or dysthymia occurs during the denominator identification period (11/01/2022 to 10/31/2023). Patients may be assessed using PHQ-9 or PHQ-9M up to 7 days prior to the encounter (including the day of the encounter).
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Measure Assessment Period: The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days) in length to allow for a follow-up PHQ-9 or PHQ-9M between 10 and 14 months following the index event. This assessment period is fixed and does not “start over” with a higher PHQ-9 or PHQ-9M that may occur after the index event date.
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Remission: Is defined as a PHQ-9 or PHQ-9M score of less than five.
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Twelve Months: Is defined as the point in time from the index event date extending out twelve months and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 or PHQ-9M score less than five obtained during this four month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission).
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Guidance:
When an index assessment is conducted with PHQ-9M, the follow-up assessment can use either a PHQ-9M or PHQ-9.
2024 Changes
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Removed denominator exclusion:
Patients who were permanent nursing home residents any time during denominator identification period or the measure assessment period.
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
HCPCS G9509 - Adult patients 18 years of age or older with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5
HCPCS M1019 - Adolescent patients 12 to 17 years of age with major depression or dysthymia who reached remission at twelve months as demonstrated by a twelve month (+/-60 days) PHQ-9 or PHQ-9M score of less than 5
ACO-20 (PREV-5)
Breast Cancer Screening
Measure Description
Percentage of women 40-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period.
Denominator
Women 41-74 years of age on the date of the encounter with a visit during the measurement period.
​
Denominator Note: The intent of the measure is that starting at age 40 women should have one or more mammograms every 24 months with a 3 month grace period.
​
Denominator Exclusions:
Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and left unilateral mastectomy.
or
Patients age 66 and older in institutional special needs plans (SNP) or residing in long-term care with a POS 32, 33, 34, 54 or 56 for more than 90 consecutive days during the measurement period.
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.
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.
Dementia Exclusion Medications
Cholinesterase inhibitors - Donepezil, Rivastigmine, Galantamine
Miscellaneous central nervous system agents - Memantine
Dementia combinations - Donepezil-memantine
Denominator Exceptions:
None
​
Numerator
Women with one or more mammograms any time on or between October 1 two years prior to the measurement period and the end of the measurement period.
Definition
Mammography screening is defined by a bilateral screening (both breasts) of breast tissue. If only one breast is present, unilateral screening (one side) must be performed on the remaining breast.
​
Guidance
This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.
​
Note
The mammogram should occur within the 27 months prior to the end of the measurement period, and may include screenings performed before the patient was 41 years old.
2024 Changes
​
Initial population: Updated to women 40-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period. In previous years, the measure was applicable to patients 50-74 years of age.
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Denominator Exclusion(s):
For 2024 Dementia combination Donepezil-memantine is added to the dementia medication exclusion list.
​
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
CPT 77065 - Diagnostic mammography, including computer-aided detection (CAD) when performed; unilateral
CPT 77066 - Diagnostic mammography, including computer-aided detection (CAD) when performed; bilateral
CPT 77067 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed
HCPCS G0202 - Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (cad) when performed
HCPCS G0204 - Diagnostic mammography, including computer-aided detection (cad) when performed; bilateral
HCPCS G0206 - Diagnostic mammography, including computer-aided detection (cad) when performed; unilateral
CPT II 3014F - Screening mammography results documented and reviewed (PV)
HCPCS G9899 - Screening, diagnostic, film, digital or digital breast tomosynthesis (3D) mammography results documented and reviewed
ACO-19 (PREV-6)
Colorectal Cancer Screening
Measure Description
Percentage of adults 45-75 years of age who had appropriate screening for colorectal cancer
Denominator
Patients 45-75 years of age who had appropriate screening for colorectal cancer
Denominator Exclusions:
Patients with a diagnosis or past history of total colectomy or colorectal cancer
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.
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.
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.
Dementia Exclusion Medications
Cholinesterase inhibitors - Donepezil, Rivastigmine, Galantamine
Miscellaneous central nervous system agents - Memantine
Dementia combinations - Donepezil-memantine
Denominator Exceptions:
None
​
Numerator
Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:
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Fecal occult blood test (FBOT) during the measurement period
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Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period.
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Colonoscopy during the measurement period or the nine years prior to the measurement period
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Stool DNA (sDNA) with FIT test during the measurement period or the the two years prior to the measurement period
-
Computed tomography (CT) Colonoscopy during the measurement period or the four years prior to the measurement period
Guidance
-
Do not count digital rectal exams (DRE)-acquired fecal occult blood tests (FOBTs) performed in an office setting or performed on a sample collected via DRE.
Note: The screening must occur in the period of time specified in the numerator. Screenings may occur before the patient turns 45.
2024 Changes
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Denominator Exclusion(s):
For 2024 Dementia combination Donepezil-memantine is added to the dementia medication exclusion list.
​
Numerator Description update:
Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the the two years prior to the measurement period has been updated to read: Stool DNA (sDNA) with FIT test during the measurement period or the the two years prior to the measurement period
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
CPT II 3017F - Colorectal cancer screening results documented and reviewed (PV)
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Measure Description
Percentage of patients aged 6 months and older seen for a visit during the measurement period who received an influenza immunization OR who reported previous receipt of an influenza immunization
Denominator
All patients aged 6 months and older seen for a visit during the measurement period.
Denominator Note: For the purposes of the program, in order to submit on the flu season 2023- 2024, the patient must have a qualifying encounter between January 1 and March 31, 2024. In order to submit on the flu season 2024-2025, the patient must have a qualifying encounter between October 1 and December 31, 2024. A qualifying encounter needs to occur within the flu season that is being submitted; any additional encounter(s) may occur at any time within the measurement period.
Denominator Exclusions:
Anaphylaxis due to the vaccine during or before the measurement period
Denominator Exceptions:
-
Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons)
-
Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons)
-
Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons)
Numerator
Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization
​Definition:
Previous Receipt: receipt of the current season's influenza immunization from another provider OR from the same provider prior to the visit to which the measure is applied
Guidance
The numerator for this measure can be met by submitting either administration of an influenza vaccination or that the patient reported previous receipt of the current season’s influenza immunization. If submitting this measure for a qualifying encounter between January 1, 2024 and March 31, 2024, influenza immunization should administered to the patient during the months of August, September, October, November, or December of 2023 or January, February, or March of 2024 for the flu season ending March 31, 2024. If submitting this measure for a qualifying encounter between October 1, 2024 and December 31, 2024, influenza immunization should be administered to the patient during the months of August, September, October, November, or December of 2024 for the flu season ending March 31, 2025. If the patient had a qualifying encounter between January 1, 2024 and March 31, 2024 AND a qualifying encounter between October 1, 2024 and December 31, 2024, the patient must have documentation showing receipt of immunization during the 2023-2024 flu season AND the 2024-2025 flu season. If the performance of the numerator is not met, an eligible clinician can submit a valid denominator exception for having not administered an influenza vaccination. For eligible clinicians submitting a denominator exception for this measure, there should be a clear rationale and documented reason for not administering an influenza immunization if the patient did not indicate previous receipt, which could include a medical reason (e.g., patient allergy), patient reason (e.g., patient declined), or system reason (e.g., vaccination not available). The system reason should be indicated only for cases of disruption or shortage of influenza vaccination supply.
​
Denominator Exception(s) are determined at the time of the denominator eligible encounter during the current flu season.
2024 Changes
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Denominator Exclusion(s):
For 2024 Anaphylaxis due to the vaccine during or before the measurement period has been added.
ACO-17 (PREV-10)
Tobacco Use: Screening and Cessation Intervention
Measure Description
Percentage of patients age 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.
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Three rates are reported:
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Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period.
-
Percentage of patients aged 12 years and older who were identified as a tobacco user during the measurement period who received tobacco cessation intervention during the measurement period or in the 6 months prior to the measurement period.
-
Percentage of patients aged 12 years and older who were screened for tobacco use one or more times during the measurement period AND who received tobacco cessation intervention during the measurement period or in the 6 months prior to the measurement period if identified as a tobacco user.
Denominator
Population 1: All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period.
Population 2: All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period and who were screened for tobacco use during the measurement period and identified as a tobacco user.
Population 3: All patients aged 12 years and older seen for at least two visits or at least one preventive visit during the measurement period.
Denominator Exclusions:
None
Denominator Exceptions:
None
Numerator
Population 1: Patients who were screened for tobacco use at least once during the measurement period.
Population 2: Patients who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period.
Population 3: Patients who were screened for tobacco use at least once during the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.
Definitions:
Tobacco Use - Use of any tobacco product
​
The 2021 USPSTF recommendation references the US Food and Drug Administration definition of tobacco which includes “any product made or derived from tobacco intended for human consumption (except products that meet the definition of drugs), including, but not limited to, cigarettes, cigars (including cigarillos and little cigars), dissolvables, hookah tobacco, nicotine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco products (including dip, snuff, snus, and chewing tobacco), vapes, electronic cigarettes (e-cigarettes), hookah pens, and other electronic nicotine delivery systems.”
The 2021 USPSTF recommendation describes smoking as generally referring to “the inhaling and exhaling of smoke produced by combustible tobacco products such as cigarettes, cigars, and pipes.”
The 2021 USPSTF recommendation describes vaping as “the inhaling and exhaling of aerosols produced by e-cigarettes.” In addition, it states, “vaping products (i.e. e-cigarettes) usually contain nicotine, which is the addictive ingredient in tobacco. Substances other than tobacco can also be used to smoke or vape. While the 2015 USPSTF recommendation statement used the term ‘electronic nicotine delivery systems’ or ‘ENDS,’ the USPSTF recognizes that the field has shifted to using the term ‘e-cigarettes’ (or ‘e-cigs’) and uses the term e-cigarettes in the current recommendation statement. E-cigarettes can come in many shapes and sizes, but generally they heat a liquid that contains nicotine (the addictive drug in tobacco) to produce an aerosol (or ‘vapor’) that is inhaled (‘vaped’) by users.”
​
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Tobacco Cessation Intervention - Includes brief counseling (3 minutes or less), and/or pharmacotherapy.
Note: Concepts aligned with brief counseling (e.g., minimal and intensive advise/counseling interventions conducted both in person and over the phone) are included in the 2023 CMS Web Interface PREV-10 Coding Document for the numerator. Other concepts such as written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies are not included in the 2023 CMS Web Interface PREV-10 Coding Document and do not qualify for the numerator. Counseling also may be of longer duration or be performed more frequently, as evidence shows higher-intensity interventions are associated with higher tobacco cessation rates (U.S. Preventive Services Task Forse, 2021).
Guidance
The requirement of two or more visits is to establish that the eligible clinician has an existing relationship with the patient for certain types of encounters.
To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements.
If a patient uses any type of tobacco (i.e., smokes or uses smokeless tobacco), the expectation is that they should receive tobacco cessation intervention: either counseling and/or pharmacotherapy.
As noted in Appendix III in the 2021 USPSTF recommendation statement, the current evidence is insufficient to recommend electronic cigarettes (e-cigarettes) for tobacco cessation. However, as noted above in the Definition section, the 2021 USPSTF recommendation also references the US Food and Drug Administration definition of tobacco, which includes e-cigarettes, hookah pens and other electronic nicotine delivery systems. Therefore, the measure does consider the use of e-cigarettes and other electronic nicotine delivery systems to be tobacco use.
If a patient’s tobacco use status is unknown, the patient does not meet the screening requirement and does not meet the numerator for populations 1 or 3. Instances where tobacco use status of “unknown” include: 1) the patient was not screened; or 2) the patient was screened and the patient (or caregiver) was unable to provide a definitive answer.
In order to promote a team-based approach to patient care, the tobacco cessation intervention can be performed by another healthcare provider; therefore, the tobacco use screening and tobacco cessation intervention do not need to be performed by the same provider or clinician.
This measure contains three reporting rates which aim to identify patients who were screened for tobacco use (rate/population 1), patients who were identified as tobacco users and who received a tobacco cessation intervention (rate/population 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (rate/population 3). By separating this measure into various reporting rates, the eligible clinician will be able to better ascertain where gaps in performance exist, and identify opportunities for improvement. The overall rate (rate/population 3) can be utilized to compare performance to published versions of this measure prior to the 2018 performance year, when the measure had a single performance rate. For accountability reporting in the CMS Medicare Shared Savings Program, the rate for population 2 is used for performance.
The denominator of population criteria 2 is a subset of the resulting numerator for population criteria 1, as population criteria 2 is limited to assessing if patients identified as tobacco users received an appropriate tobacco cessation intervention. For all patients, population criteria 1 and 3 are applicable, but population criteria 2 will only be applicable for those patients who are identified as tobacco users. Therefore, data for every patient that meets the age and initial population criteria will only be submitted for population 1 and 3, whereas data submitted for population 2 will be for a subset of patients who meet the initial population criteria, as the denominator has been further limited to those who were identified as tobacco users.
2024 Changes
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Updated initial population: Percentage of patients aged 12 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period if identified as a tobacco user.
​
Previously this measure looked at patients aged 18 years and older.
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
HCPCS II G0030 - Patient screened for tobacco use and received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling, pharmacotherapy, or both), if identified as a tobacco user
HCPCS II G9903 - Tobacco user screen- Identified Non-user
HCPCS II G9906 - Patient identified as a tobacco user received tobacco cessation intervention during the measurement period or in the six months prior to the measurement period (counseling and/or pharmacotherapy)
CPT 1036F - Current tobacco non-user (CAD, CAP, COPD, PV) (DM) (IBD)
ACO-18 (PREV-12)
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 Exclusions:
Patients who have been diagnosed with bipolar disorder
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.)
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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:
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Adolescent Screening Tools (12-17 years)
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Patient Health Questionnaire for Adolescents (PHQ-A)​
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Beck Depression Inventory-Primary Care Version (BDI-PC)
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Mood Feeling Questionnaire (MFQ)
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Center for Epidemiologic Studies Depression Scale (CES-D)
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Patient Health Questionnaire (PHQ-9)
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Pediatric Symptom Checklist (PSC-17)
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Prime MD-PHQ-2
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Adult Screening Tools (18 years and older)​
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Patient Health Questionnaire (PHQ-9)
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Beck Depression Inventory (BDI or BDI-II)
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Center for Epidemiologic Studies Depression Scale (CES-D)
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Depression Scale (DEPS)
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Duke Anxiety-Depression Scale (DADS)
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Geriatric Depression Scale (GDS)
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Cornell Scale for Depression in Dementia (CSDD)
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Prime MD-PHQ-2
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Hamilton Rating Scale for Depression (HAM-D)
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Quick Inventory of Depressive Symptomatology Self-Report (QID-SR)
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Computerized Adaptive Testing Depression Inventory (CAT-DI)
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Computerized Adaptive Diagnostic Screener (CAD-MDD)
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Perinatal Screening Tools​
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Edinburgh Postnatal Depression Scale
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Postpartum Depression Screening Scale
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Patient Health Questionnaire 9 (PHQ-9)
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Beck Depression Inventory
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Beck Depression Inventory -II
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Center for Epidemiologic Studies Depression Scale
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Zung Self-rating Depression Scale
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Follow-up Plan​ - Documented follow-up for a positive depression screening must include one or more of the following:
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Referral to a clinician for additional evaluation and assessment to formulate a follow-up plan for a positive depression screen
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Pharmacological interventions
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Other interventions or follow-up for the diagnosis or treatment of depression
Guidance
A depression screen is completed on the date of the qualifying 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 qualifying encounter , such as a referral to a clinician 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.
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This is a patient-based measure. Depression screening is required once per measurement period, not at all encounters.
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This measure requires documentation that a screening was conducted with a standardized depression screening tool. It is recommended that both a score and clinician interpretation of the score is documented, especially when a patient screens positive. At a minimum, the medical record must contain documentation of the tool’s name and results of the screening with a score OR clinician interpretation of positive or negative for depression. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression. A score interpreted as positive requires documentation of a follow-up plan. A score interpreted as negative does not require a follow-up plan.
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The intent of the measure is to screen for new cases of depression in patients who have never had a diagnosis of bipolar disorder prior to the qualifying encounter used to evaluate the numerator. Patients who have been diagnosed with bipolar disorder will be excluded from the measure.
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Screening Tools:
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An age appropriate standardized, and validated depression screening tool must be used for numerator compliance.
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The name of the age appropriate standardized depression screening tool must be documented in the medical record.
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The depression screening must be reviewed and addressed by the clinician, filing the code, 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 clinician practice. The screening should occur during a qualifying encounter or up to 14 calendar days prior to the date of the qualifying encounter
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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. 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.
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Follow-up Plan:​
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For a depression screen deemed positive, 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 clinician’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.
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The follow-up plan must be related to a positive depression screening, for example: "Patient referred for psychiatric evaluation due to positive depression screening."
Examples of a follow-up plan include but are not limited to:​
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Referral to a clinician, practitioner, 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
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Other interventions designed to treat depression such as behavioral health evaluation, psychotherapy, pharmacological interventions, or additional treatment options
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Should a patient screen positive for depression a clinician should:
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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.
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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.
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2024 Changes
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Updated exclusions: Removed diagnosis of depression from the exclusions
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
HCPCS II G8431 - Screening for depression is documented as being positive and a follow-up plan is documented
HCPCS II G8510 - Screening for depression is documented as negative, a follow-up plan is not required
ACO-42 (PREV-13)
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
Measure Description
Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period:
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All patients who were previously diagnosed with or currently have a diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD), including an ASCVD procedure; OR
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Patients aged 20-75 years who have ever had a low-density lipoprotein cholesterol (LDL-C) level >190 mg/dl or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia; OR
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Patients aged 40-75 years with a diagnosis of diabetes; OR
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Patients aged 40-75 with a 10-year ASCVD risk score of > 20 percent
Denominator
All patients who meet one or more of the following criteria (considered at "high risk" for cardiovascular events, under ACC/AHA guidelines).
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All patients who were previously diagnosed with or currently have a diagnosis of clinical ASCVD, including an ASCVD procedure.​
2. Patients aged 20 to 75 years at the beginning of the measurement period who have ever had laboratory result of LDL-C >190 mg/dl or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia​
3. Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes.
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4. Patients aged 40 to 75 years at the beginning of the measurement period with a 10-year ASCVD risk score of >20 percent during the measurement period.
Denominator Exclusions:
Patients who are breastfeeding at any time during the measurement period.
Patients who have a diagnosis of rhabdomyolysis at any time during the measurement period.
Denominator Exceptions:
Patients with statin-associated muscle symptoms or an allergy to statin medication
Patients with active liver disease or hepatic disease or insufficiency
Patients with end-stage renal disease (ESRD)
Patients with documentation of a medical reason for not being prescribed statin therapy
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Denominator Population Guidance for Encounter:
In order for the patient to be included in the denominator, the patient must have ONE denominator-eligible visit, defined as follows: Outpatient visit, initial or established office visit, face-to-face interaction, preventive care services, or annual wellness visit.
LDL-C Laboratory test result options:
The measure can be reported for all patients with a documented LDL-C level recorded as follows:
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To meet Denominator Population 1:
There is no LDL-C result required.
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To meet Denominator Population 2:
If a patient has ANY previous laboratory result of LDL-C >190mg/dL, report the highest value > 190 mg/dL
To meet Denominator Population 3:
There is no LDL-C result required.
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To meet Denominator Population 4:
There is no LDL-C result required.
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Numerator
Patients who are actively using or who receive an order (prescription) for statin therapy at any time during the measurement period.
Note: In order to meet the measure, current statin therapy use must be documented in the patient's current medication list or ordered during the measurement period. ONLY statin therapy meets the measure Numerator criteria (NOT other cholesterol lowering medications.) Prescription or order does NOT need to be linked to an encounter or visit; it may be called to the pharmacy. Statin medication "samples" provided to patients can be documented as "current statin therapy" if documented in the medication list in health/medical record. Patients who meet the denominator criteria for inclusion, but are not prescribed or using statin therapy, will NOT meet performance for this measure unless they have an allowable denominator exception. Adherence to statin therapy is not calculated in this measure. Denominator exceptions should be active during the measurement period.
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It may not be appropriate to prescribe statin therapy for some patients (see exceptions and exclusions for the complete list).
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Definitions
Clinical atherosclerotic cardiovascular disease (ASCVD) includes:
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Acute coronary syndromes
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History of myocardial infraction
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Stable or unstable angina
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Coronary or other arterial revascularization
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Stroke or transient ischemic attack (TIA)
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Peripheral arterial disease of atherosclerotic origin
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Lipoprotein Density Cholesterol (LDL-C) result: A fasting or non-fasting LDL-C laboratory test performed and direct or calculated test result documented in the medical record. When both direct and calculated test results are available on the same day, the direct LDL-C test should be used.
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Statin Therapy: Administration of one or more of a group of medications that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.
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Statin Medication Therapy List (Note: List does NOT include dosage):
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Statin Associated Muscle Symptoms (SAMS) - The 2018 ACC/AHA/MS Guideline (Grundy et al., 2019) includes the following SAMS: myalgias, myositis, myopathy or statin-associated autoimmune myopathy. Patients who experience significant or repeated statin-associated muscle symptoms may prefer not to take or continue statin therapy and therefore may be removed from the denominator.
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10 Year Risk Assessment - The 10-year ASCVD risk score is calculated using the Pooled Cohort Equations: 1) the 2013 ACC/AHA ASCVD Risk Estimator OR 2) the ACC Risk Estimator Plus. If your EHR does not have either of these risk calculators, we recommend that you use the on-line versions. The 10-year ASCVD risk assessment must be performed during the measurement period.
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Intensity of statin therapy in primary and secondary prevention:
The expert panel of the 2018 ACC/AHA/MS Guidelines (Grundy et al. 2019) defines recommended intensity of statin therapy on the basis of the average expected LDL-C response to specific statin and dose. Although intensity of statin therapy is important in managing cholesterol, this measure assesses prescription of ANY statin therapy, irrespective of intensity. Assessment of appropriate intensity and dosage documentation added too much complexity to allow inclusion of statin therapy intensity in the measure at this time.
2024 Changes
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Risk Category changes:
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Risk Category 2 has been updated to "Patients aged 20 to 75 years at the beginning of the measurement period who have ever had laboratory result of LDL-C >190 mg/dl or were previously diagnosed with or currently have an active diagnosis of familial hypercholesterolemia" Previously this was patients >20 years of age.
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Risk Category 4 has been added "Patients aged 40 to 75 years at the beginning of the measurement period with a 10-year ASCVD risk score of >20 percent during the measurement period."
Additional Codes used by Health Endeavors
These codes are not in the current CMS Specs, however, Health Endeavors is using these codes as helpful codes to help answer some measures. Codes highlighted in yellow indicate that the respective code is only used to show claims icon/details from the helpful claim and cannot be used to populate a measure answer due to insufficient data.
HCPCS II G9664 - Patients who are currently statin therapy users or received an order (prescription) for statin therapy