The first filter under Form Filters is for patient search. You can search for a patient by :
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HICN - Health Insurance Claim Number
MBI - Medicare Beneficiary Identifier
Last Name - Patient Last Name
First Name - Patient First Name
MRN - Medical Record Number
DOB - Patient Date of Birth
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For DOB you must use the exact date. All other searches you can choose from one of the following options:
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Starts With - Based on patient data that begins with the text entered
Exact Match - Based on an Exact Match to patient data entered
Ends With - Based on patient data that ends with the text entered.
The next search filter is for TIN and Facility. You have the options to search by:
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TIN - Taxpayer Identification Number of practice patients belong to.
Facility Name - Name of Associated Care Facility
Facility Number Facility Number of Associated Care Facility
Facility Division - Choose from list of divisions for your organization (if applicable)
Sub-TIN - Choose from Sub-Tin of practice to which they belong
NPI - National Provider Identification Number of provider patient belong to
Provider Name - Name of provider patient belongs to
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As above users may search by Starts with, Exact Match or Ends with.
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Patient claims Filters - Allows users to search patient claims data relevant to the quality measure responses. Multiple measures may be selected in this filter, and patients with claims data in at least one of the selected measures will be included in the search results.
Module and Module Status - These filters will narrow the patient list search results based on patients with response data matching the choices in the 'Module Status' section for the quality measures chosen in the "Module' section.
Complete (C) - Quality measure is complete with a performance response.
Complete with Non-Performance Answer (CNP) - Quality measure is complete with a non-performance response
Exception (Medical, Patient, System Reason) (E) - Quality measure is exempt due to specific response circumstances
Skipped (S) - Patient does not qualify for this measure based on measure-specific restrictions such as age or gender.
Incomplete (I) - Patient response to this quality measure has not been submitted
Patient Responses - Allows users to select one measure and potential responses to that measure. Results will show patients that meet the specified criteria.
Patient Quality Score - Filter shows patients with an overall quality measure score between the two percentages entered. This can be useful to help prioritize patients with lower scores.
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Patient Progress Score - Filter shows patients whose completed measures fall between two entered values. Like the Quality Score, this can be useful for finding patients with few or no quality measures completed.
Patient Questionnaire Status- Search filter shows patients whose overall questionnaire has one of the four primary Status. More than one status can be selected, and will display patients with one of the selected statuses.
Green - Questionnaire Completed
Blue - Questionnaire In Progress
Red - Questionnaire Not Started
Yellow - Questionnaire Skipped
Data Source Filter - Shows patients with measures that have been filled out through one of several different methods.
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EMR Import - Measures answered by an EMR file, a large import file that is imported via a specialized back-end process
Claims Import - One or more measures answered by a CCLF claim file from CMS. Eligible measures are automatically answered in this way based on claims data for the patient.
Manually Keyed - One or more measures answered manually by a user within the system.
Single/Spec File - Searches for patients with one or more measures answered using either Single or Spec File spreadsheet uploads in the system.
Not Done/No Dx - Patients with one or more measures filled in as either non-performance or no diagnosis. This is often due to an absence of response, and is usually replaced by a true answer or data at a later time.
N/A Age/Gender - Patients who were skipped in one or more measures based on age or gender disqualifications
Carried Over - Patients with one or more measures filled in with an answer from a previous year.
EMR Import and Single/Spec File imports - These imports have additional parameters available. Once you select one of the options you will see and option to choose the Import date From /To fields to narrow your search down to a smaller list of files. The Import files lists all files that were placed into the system during that date range and allows you to select one. If you do not enter a date range you will see the full list of files.
Deceased / Living Status Options - Search filter will show patients that are in the system as either alive or deceased. By default, both are selected.
Medical Record Status - Filter allows you to filter results based on the availability of medical records for patients, or allows for filtering of just patients who are not qualified for sampling.
Once you have the desired search filters selected, click the button to generate results in the patient list. Alternatively, click the to remove all selected filters and start the search form anew.
Form Filters
Chart Filters
Chart Filters are located directly below the Form Filters. To access the chart Filters click on the green plus sign. These filters will show your ACOs current progress based on a ratio of responses for each measure. The bars in each row when added together, total 100% for each of the quality measures. Hover over a section of the bar and a pop-up will show the measure, type of response being measured, and the current number of patients in that response type. If you click on a section of the bar the patient grid will filter to those patients in the patient grid below. This will also adjust the filter options in the form filters above. This chart is updated in real time, so as you manually enter answers or files are uploaded you will see the charts update accordingly.
Yellow Bar - Indicates patients Not Qualified for the measure.
Orange Bar - Indicates patients Skipped / Non-Applicable (N/A) for the measure
Blue Bar - Indicates patients with a Performance Answer for the measure
Lavender Bar - Indicates Patients with an Exception/Exclusion for the measure
Red Bar - Indicates Patients with a Non-Performance Answer for the measure
Gray Bar - Indicates Patients that are currently incomplete.
QM Dashboard
QM Dashboard is located directly below the Chart Filters. To access the QM Dashboard click on the green plus sign. The QM Dashboard gives users an overview of their CMS Web Interface completion throughout the year.
The blue bar shows your Quality Measures Completion percentage and Quality Measures Remaining (number of incomplete patients). For a patient to show as complete all measures must be completed.
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The pie chart shows your current Incomplete, Complete and Not Qualified patient percentages. While the Bar Graph shows your patient completion per month.
The QM Completion Leaderboard shows each practice for your ACO. For each practice you will see Total Patients, Number of Completed Patients, % Complete Change from Last Month, Number of not Qualified Patients and % of not Qualified Patients.
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Use the Export button to export the Completion Leaderboard to an Excel File.
Patient Grid
Patient List - Can be found directly below the form and chart filters. By default all accessible patients are displayed. As filters are used, the list will become more specialized. The first half of the patient list shows all basic patient information. This includes patient's HICN, MBI, MRN, First and Last Name, Date of Birth and living Status, current Quality Score Percentage, current Progress Score. The next section covers Division, Facility Name, TIN, Sub-TIN, Facility Number, Provider Name, and NPI which the patient is assigned.
At the top of the patient list window, there are two buttons, . Clicking on Excel Export will send a request for a QM Questionnaire Report. This report is not generated immediately, but instead appears just below the Chart Filters section after the request has been completed. Please note this can take several minutes for the report to generate. Clicking Clear Search Criteria will remove any search filters and show all available patient data.
The far left Action column of the patient list contains links to two other sections. The right icon which is either a blue circle or a blue notepad, ( , ) leads to the patient chart and claims data window. The left icon, a colored flag, ( ) leads to the quality measures questionnaire page.
The patient list also contains a summary of current quality measure data on the right half of the table.
Clicking in the measure box will open a window containing that measure. If the answer is already filled in the information will be available for viewing. If you wish to manually key the information for the measure, you may fill in a response or update a response and click .
PREV-7
**Note: The PREV-7 measure for the 2023 performance year includes 2 Flu Seasons.
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PREV-7 Flu Season 2022-2023 - In order to submit on the flu season 2022-2023, the patient must have a qualifying encounter between January 1 and March 31, 2023. Influenza immunization should be administered to the patient during the months of August, September, October November or December 2022 or January, February, or March 2023.
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PREV-7 Flu Season 2023-2024 - In order to submit on the flu season 2023-2024, the patient must have a qualifying encounter between October 1 and December 31, 2023. Influenza immunization should be administered to the patient during the months of August, September, November or December 2023.
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Based on the updated documentation (Measures Metadata) released by CMS in the QPP Developer Tool and conversations with CMS, Health Endeavors has updated the PREV-7 measure into two measures in the quality patient grid.
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Please note that not all patients will qualify for both 2022-2023 and 2023-2024. Patients will be sampled into one or both flu seasons and you'll be required to report the numerator outcome for the flu season(s) for which they're sampled. The CMS Random Sample file will indicate which flu season each patient is sampled for. Once Health Endeavors has imported your sample in the CMS Web Interface Random Sample 2023 you will find that you will only be able to answer for the flu season(s) you need to report on per patient. The other measure will be disabled.
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For patients sampled into one flu season (2022-2023 OR 2023-2024), performance will be calculated based on the numerator action reported for the applicable flu season.
For patients sampled into both flu seasons, performance is aggregated based on the outcome reported for each (they're counted once in the denominator and once in the numerator).
• Performance Met
This is the outcome if the patient has documentation showing receipt of immunization for the 2022-2023 flu season AND the 2023-2024 flu season.
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If performance is met for one flu season and the patient had a documented denominator exception for the other flu season.
• Denominator Exception
This is the outcome if there is a documented denominator exception for both flu seasons.
• Performance Not Met
This is the outcome when patient doesn't receive the influenza immunization for one or both flu seasons.
OR
If the patient qualified for a denominator exception for one flu season and didn't receive the immunization for the other flu season, it would be considered performance not met (e.g., immunization wasn't administered for the 2022 – 2023 flu season and a denominator exception was documented for the 2023 – 2024 flu season).
GREEN C = Complete Module - performance answer. This answer means that the quality action was successfully completed as requested per measure requirement. Patient met the numerator criteria. This answer improves ACO quality performance.
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Example is:
'Mammogram performed during the measurement period or the 15 months prior to the measurement period" (for PREV-5 measure)
RED C = Complete Module - non-performance answer. This answer means that the quality action was not completed in accordance with the measure requirements. Patient did not meet numerator criteria. It can be that the quality action was not completed at all or it was completed but the outcome is not as requested by measure steward. This answer lowers ACO quality performance.
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Examples are:
"Most recent BP NOT controlled (> 140mmHg systolic and/or > 90mmHg diastolic)'
'Patient did NOT have BP measurement performed, no medical reason given' (for HTN measure)
There are two options that will remove a patient either from the measure or measure's performance calculation. Measure owners may specify a patient should be excluded from the denominator of a particular measure (denominator exclusion) or from the calculation of performance for the measure (denominator exception). For measure where the measure owner has identified an appropriate denominator exclusion and/or denominator exception category, it will be specified within the 2022 CMS Web Interface measure specifications or support documents.
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ORANGE S = Skipped (N/A). This answer represents a denominator exclusion. It means that the patient should be removed from the measure population and denominator before determining whether the numerator criteria are met. If a patient meets the denominator exclusion criteria, they mush be removed from the measure population. If this patient is included in the random sample for quality reporting, the patient will be replaced with the next consecutive patient sampled for the measure.
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Example is:
'N/A (Patient does not have a diagnosis of Diabetes Mellitus.)' (for DM measure)
BLUE C = Complete Module - medical or other exception (not scored). This answer represents a denominator exception - when a patient is eligible for the denominator, but the measure specifications define circumstances in which a patient may be appropriately deemed as as denominator exception. There are 3 general categories of allowable reasons:
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Medical
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Patient
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System
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A denominator exception removes a patient from the performance denominator only if the numerator criteria aren't met, as defined by the exception. This allows for the exercise of clinical judgement by the MIPS eligible clinician. When a denominator exception is selected, the patient is considered completed for reporting and does not have to be replaced with another patient if included in the reporting sample.
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Example is:
'Patient not vaccinated due to medical reason, documentation in record (e.g. allergy)' (for PREV-7 measure)
- Patient has claims data. Clicking in the box with this icon will bring up a window with the ability to click on 'Claims' and view applicable claims. .
If there is no status letter in the grid, measure is incomplete i.e. no data is provided for the measure.
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Please note that patient can also be marked as 'Not Qualified' for quality reporting if they have one of the 4 acceptable reasons:
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In Hospice
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Moved of of Country
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Deceased
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HMO Enrollment
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In this case, they will have a yellow flag for their questionnaire status and measure fields will be blank and not clickable.
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Answer Option Definitions
To access the Patient Quality Measure Questionnaire, click on the colored flag ( ) to the far left of the patient grid in the 'Action' column.
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The top of the questionnaire page shows the patient's basic information, Medical Record Status, and measure completion progress.
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If the patient is 'Not Qualified for Sample', a reason must be selected and the date the patient become not qualified must be entered.
Each quality measure will be outlined below the patient information. If the measure shows a response you will see the measure status in the green bar at the top of the measure section.
If data already exists, then the date and form of the data submission is shown in red font. In addition, the option to manually key the data is available, whether prior data for the measure exists or not.
For every measure there is a response highlighted in Purple. This is considered a non-performance response.
Some measures may contain associated claims data, also known as 'CCLF Data'. A summary of each claim will be listed within the measure itself. Click on the Red claims bar and the bar will open with additional information.
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You may also view claims by clicking on the Blue Paper icon in the 'Action' column and clicking on the 'Patient Lookup' tab.
Some measures may also contain historical data if the patient's response data has been saved more than once. Under the 'History' tab you may find previous service dates and comments for specific quality measures. Click on the to open and view historical data.
