ACO - CMS Web Interface (APP)

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 with a visit during the measurement period. 

Numerator

Patients who were screened for future fall risk at least once within the measurement period.

Definitions

 

Screening for Future Fall Risk: 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. 

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. 

 

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. 

Numerator

Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%.

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. If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance.

Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of the measure; patients with a diagnosis of secondary diabetes due to another condition should not be included.

 

ACO-28 (HTN-2)

Controlling High Blood Pressure

Measure Description

Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping 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 overlapping the measurement period. 

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 a remote monitoring devise are acceptable for numerator compliance with this measure. 

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.

  • Reported or taken by the member

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. 

 

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- Modified for Teens and Adolescents (PHQ-9M) score greater than nine during the index event. 

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 11/1/2019 to 10/31/2020. For patients with an index even, 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.

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 (11/01/2019 to 10/31/2020). Patients may be screened using PHQ-9 or PHQ-9M up to seven days prior to the encounter (including the day of the encounter).

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). This 14 month measure assessment period allows for measurement of the patients remission status at both six and 12 months (Quality ID#441: Depression Remission at Six Months). 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.

Remission: Is defined as a PHQ-9 or PHQ-9M score of less than five.

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 and 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).

 

ACO-20 (PREV-5)

Breast Cancer Screening

Measure Description

Percentage of women 50-74 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 51-74 years of age with a visit during the measurement period.

Numerator

Women with one or more mammograms during the 27 months prior to 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.

 

ACO-19 (PREV-6)

Colorectal Cancer Screening

Measure Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Denominator

Patients 50-75 years of age with a visit during the measurement period. 

Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

  • Fecal occult blood test (FBOT) during the measurement period

  • Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period.

  • Colonoscopy during the measurement period or the nine years prior to the measurement period

  • Fecal immunochemical DNA test (FIT-DNA) 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

  • FOBT: It is up to the organization to determine whether the specific test or bran meets the definition

  • Do not count DRE, FOBT test performed in an office setting or performed on a sample collected via DRE.

  • Documentation in the medical record must include both of the following: A note indicating the date the colorectal cancer screening was performed AND the result or findings.

  • Documentation of 'normal' or 'abnormal' is acceptable

  • Patient Reported Requirement: Date (year) and type of test AND result/finding

  • Documentation of colorectal cancer screening may be completed during a telehealth encounter.

 

ACO-14 (PREV-7)

Influenza Immunization

Measure Description

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 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.

 

Numerator

Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization between August 1, 2020 and March 31, 2021.

 

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 (typically, prior vaccination would include influenza vaccine given since August 1st)

Guidance

To enable reporting of this measure at the close of the reporting period, this measure will only access the influenza season that ends in March of the reporting period. The subsequent influenza season (ending March of the following year) will be measured and reported in the following year. 

Due to the changing nature of the CDC/ACIP recommendations regarding the live attenuated influenza vaccine (LAIV) for a particular flu season, this measure will not include the administration of this specific formulation of the flu vaccination. Given the variance of the timeframes for the annual update cycles, program implementation, and publication of revised recommendations for the CDC/ACIP, it has been determined that the coding for this measure will specifically exclude this formulation, so as not to inappropriately include this form of the vaccine for flu seasons when CDC/ACIP explicitly advise against it. However, it is recommended that all eligible professionals or eligible clinicians review the guidelines for each flu season to determine appropriateness of the LAIV and other formulations of the flu vaccine. Should the LAIV be recommended for administration for a particular flu season, an eligible professional or clinician may consider one of the following options: 1) satisfy the numerator by reporting previous receipt or using the CVX 88 for unspecified formulation, 2) report a denominator exception, either as a patient reason (e.g., for patient preference) or a system reason (e.g., the institution only carries LAIV).

 

ACO-17 (PREV-10)

Tobacco Use: Screening and Cessation Intervention

Measure Description

Percentage of patients age 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.

Three rates are reported:

  1. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months.

  2. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention

  3. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as tobacco user.

Denominator

Population 1: All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement period. 

Population 2: All patients aged 18 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 and identified as a tobacco user.

Population 3: All patients aged 18 years and older seen for at least two visits or at least on preventive visit during the measurement period. 

Numerator

Population 1: Patients who were screened for tobacco use at least once within 24 months

Population 2: Patients who received tobacco cessation intervention

Population 3: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user.

Definitions:

Tobacco Use - Includes any type of tobacco

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 2021 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 2021 CMS Web Interface PREV-10 Coding Document and do not qualify for the numerator. Brief counseling also may be of longer duration or be performed more frequently, as evidence shows there is a does-response relationship between the intensity of counseling provided (either length or frequency) and tobacco cessation rate (U.S. Preventive Services Task Force, 2015).

Guidance

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.

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.

Screening for tobacco use and cessation intervention do not have to occur on the same encounter, but both must occur during the 24-month look back period.

To satisfy the intent of the measure, a patient must have at least one tobacco use screening during the 24-month period. If a patient has multiple tobacco use screenings during the 24-month 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. "Within 24 months" is defined as the 24-month look-back from the measurement period end date (01/01/2020-12/31/2021)

If tobacco use status of a patient is unknown, the patient does not meet the screening component requirement required to be counted in the numerator and should be considered a measure failure. Instances where tobacco use status of "unknown" is recorded include: 1) the patient was not screened 2) the patient was screened and the patient (or caregiver) was unable to provide a definitive answer. If the patient does not meet the screening component of the numerator but has an allowable medical exception, then the patient should be removed from the denominator of the measure and reported as a valid exception.

The medical reason exception may be applied to either the screening data element OR to any of the applicable tobacco cessation intervention data elements (counseling and/or pharmacotherapy) included in the measure.

If a patient has a diagnosis of limited life expectancy, that patient has a valid denominator exception for not being screened for tobacco use or for not receiving tobacco use cessation intervention (counseling and/or pharmacotherapy) if identified as a tobacco user.

As noted in Appendix III in a recommendation statement from the USPSTF, the current evidence is insufficient to recommend electronic nicotine delivery systems (ENDS) including electronic cigarettes for tobacco cessation. Additionally, ENDS are not currently classified as tobacco in the recent evidence review to support the update of the USPSTF recommendation given that the devices do not burn or use tobacco leaves. In light of the current lack of evidence, the measure does not currently capture e-cigarette usage as either tobacco use or a cessation aid.

The requirement of two or more visits is to establish that the eligible professional or eligible clinician has an existing relationship with the patient for certain types of encounters.

 

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 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 professional or 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 MIPS 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 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.

Screening for tobacco use may be completed during a telehealth encounter.

 

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 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 the eligible encounter.

Denominator

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

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 the eligible 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 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:

  • Additional evaluation or assessment for depression

  • Suicide Risk Assessment

  • Referral to a practitioner who is qualified to diagnose and treat depression

  • Pharmacological interventions

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

Guidance

A depression screen is completed 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, either additional evaluation for depression, suicide risk assessment, referral to a practitioner who is qualified to diagnose and treat depression is documented on the date of the eligible encounter.

Depression screening is required once per measurement period, not at all encounters; this is patient based and no an encounter based measure.

Screening Tools:

  • The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record.

  • The depression screening must be reviewed and addressed in the office of the provider 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 provider practice.

  • The screening should occur during a qualified encounter or up to 14 days prior to the date of the qualifying encounter

  • Standardized depression screening tools should be normalized and validated for the age appropriate patient population in which they are used.

Follow-up Plan:​

  • The follow-up plan must be related to a positive depression screening, example: "Patient referred for psychiatric evaluation due to positive depression screening."

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

  • Additional evaluation or assessment for depression such as psychiatric interview, psychiatric evaluation, or assessment for bipolar disorder

  • Completion of any Suicide Risk Assessment such as Beck Depression Inventory or Beck Hopelessness Scale

  • Referral to a practitioner or program for further evaluation for depression, for example, referral to a psychiatrist, psychologist, 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 psychotherapy, pharmacological interventions, or additional treatment options

  • Pharmacologic treatment for depression is often indicated during pregnancy and/or lactation. Review and discussion of the risks of untreated versus treated depression is advised. Consideration of each patient's prior disease and treatment history, along with the risk profiles for individual pharmacologic agents, is important when selecting pharmacologic therapy with the greatest likelihood of treatment effect.

The Term "active diagnosis" is defined as a diagnosis that is either on the patient's problem list, a diagnosis code description listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the measurement period.

 

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:

  • Adults aged > 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR

  • Adults aged >21 years who have never had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >190 mg/dl or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR

  • Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dl

Denominator

All patients who meet one or more of the following criteria (considered at "high risk" for cardiovascular events, under ACC/AHA guidelines). The denominator covers three distinct populations. There is only one  performance rate calculated for this measure. Use the following process to prevent counting patients more than once.

  1. Patients aged>21 years at the beginning of the measurement period with clinical ASCVD diagnosis

    • If YES, patient meets Denominator Population 1 risk category​​

    • If NO, screen for next risk category

  2. Patients aged >21 years at the beginning of the measurement period who have ever had a fasting or direct laboratory result of LDL-C >190 mg/dl or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia

    • If YES, patient meets Denominator Population 2 risk category​

    • If NO, screen for next risk category

  3. Patients aged 40 to 75 years at the beginning of the measurement period with Type 1 or Type 2 diabetes and with an LDL-C result of 70-189 mg/dl recorded as the highest fasting or direct laboratory test result in the measurement year or during the two years prior to the beginning of the measurement period

    • If YES, patient meets Denominator Population 3 risk category​

    • If NO, patient does NOT meet denominator criteria and is NOT eligible for measure inclusion

Denominator 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 encounter visit type

  • Encounter performed: initial or established office visit, face-to-face interaction, prevention care services, or annual wellness visit

LDL-C Laboratory test result options:

The measure can be reported for all patients with a documented fasting or direct LDL-C level recorded as follows:

To meet Denominator Population 1:

     There is no LDL-C result required.

To meet Denominator Population 2:

     If a patient has ANY previous fasting or direct laboratory result of LDL-C >190mg/dL, report the highest value > 190 mg/dL

To meet Denominator Population 3:

     If a patient has more than one LDL-C result during the measurement period or during the two years before the start of the measurement period, report the highest level recorded during either time. The Denominator Exception, "Patients with diabetes who have the most recent fasting or direct, LDL-C laboratory test result <70 mg/dL and are not taking statin therapy" applies only to Denominator Population 3.

Intensity of statin therapy in primary and secondary prevention:

The expert panel of the 2013  ACC/AHA Guidelines (Stone et al. 2014) defines recommended intensity of statin therapy on the basis of the average expected LDL-C response to specific statin and does. 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.

Lifestyle modification coaching:

A healthy lifestyle is important for the prevention of cardiovascular disease. However, lifestyle modification monitoring and documentation added too much complexity to allow is inclusion in the measure at this time.

Numerator

Patients who are actively using or who receive an order (prescription) for statin therapy at any point 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. Adherence to statin therapy is not calculated in this measure. Denominator exceptions should be active during the measurement period.

Definitions

Clinical atherosclerotic cardiovascular disease (ASCVD) includes:

  • Acute coronary syndromes

  • History of myocardial infraction

  • Stable or unstable angina

  • Coronary or other arterial revascularization

  • Stroke or transient ischemic attack (TIA)

  • Peripheral arterial disease of atherosclerotic origin

Lipoprotein Density Cholesterol (LDL-C) result: A fasting or direct LDL-C laboratory test performed and test result document in the medical record.

Statin Therapy: Administration of one or more of a group of medication that are used to lower plasma lipoprotein levels in the treatment of hyperlipoproteinemia.

Statin Medication Therapy List (Note: List does NOT include dosage) is included in the clinical recommendations .

Some patients may not be appropriate to prescribe or use statin therapy (see exceptions and exclusions for a complete list).

"Statin intolerance is the ability to tolerate a does of statin required to reduce a person's CV risk sufficiently from their baseline risk and could result from different statin related side effects including: muscle symptoms, headache, sleep disorders, dyspepsia, nausea, rash, alopecia, erectile dysfunction, gynecomastia and/or arthritis" (Banach, et al., 2015, p.2).

Patients that experience symptoms such as these may prefer not to take or continue statin therapy and therefore may be exempt from the denominator.