American Academy of Neurology
American Geriatrics Society
American Medical Directors Association
American Psychiatric Association
Physician Consortium for Performance Improvement® (PCPI™)
Dementia
Performance Measurement Set
PCPI Approved October 2011
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
1
Table of Contents
Executive Summary………………………………………………………………...………………………………………………..
5
Purpose of Measurement Set………………………………………………………………...……………………………………
9
Importance of Topic………………………………………………………………...………………………………………………
9
Opportunity for Improvement………………………………………………………………...………………………………….
10
Clinical Evidence Base………………………………………………………………...…………………………………………….
11
Dementia Outcomes………………………………………………………………...………………………………………………
11
Intended Audience, Care Setting, and Patient Population………………………………………………………………......
12
Dementia Work Group Recommendations………..………………………………………………………………...................
12
Other Potential Measures…………………………………………………………………………………………………………..
13
Measure Harmonization……………………………………………………………………………………………………………
14
Technical Specifications Overview………………………………………………………………..............................................
14
Testing and Implementation of the Measurement Set………………………………………………………………............
14
Measure #1: Staging of Dementia………………………………………………………………...............................................
15
Measure #2: Cognitive Assessment………………………………………………………………............................................
17
Measure #3: Functional Status Assessment……………………………………………………………….............................
19
Measure #4: Neuropsychiatric Symptom Assessment………………………………………………………………………
21
Measure #5: Management of Neuropsychiatric Symptoms………………………………………………………………...
24
Measure #6: Screening for Depressive Symptoms………………………………………………………………..................
27
Measure #7: Counseling Regarding Safety Concerns………………………………………………………………………..
29
Measure #8: Counseling regarding Risks of Driving………………………………………………………………………...
31
Measure #9: Palliative Care Counseling and Advance Care Planning……………………………………………………
33
Measure #10: Caregiver Education and Support……………………………………………………………………………..
36
Evidence Classification/Rating Schemes………………………………………………………………………………………..
38
Summary of Non-Material Interest Disclosures……………………………………………………………………………….
40
References………………………………………………………………………………………………………..……………………
41
Dementia: Administrative Claims Specifications………………………………………………………………....................
Appendix
A
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
2
Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for
Performance Improvement® (PCPI™), are intended to facilitate quality improvement activities by physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician
who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical
guidelines and do not establish a standard of medical care. The PCPI has not tested its Measures for all potential applications.
The PCPI encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the PCPI. The Measures may not be altered
without the prior written approval of the PCPI. Measures developed by the PCPI, while copyrighted, can be reproduced and
distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their
practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation
of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the
Measures require a license agreement between the user and American Medical Association, on behalf of the PCPI. Neither the
PCPI nor its members shall be responsible for any use of these Measures.
THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2011 American Medical Association. All Rights Reserved
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets
should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its members disclaim
all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.
CPT® contained in the Measures specifications is copyright 2009 American Medical Association. LOINC® copyright 2004
Regenstrief Institute, Inc. SNOMED CLINICAL TERMS (SNOMED CT®) copyright 2004 College of American Pathologists (CAP). All
Rights Reserved. Use of SNOMED CT® is only authorized within the United States.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
3
Work Group Members
Dementia
Work Group Members
Jerry C. Johnson, MD (Co-Chair) (geriatric medicine)
Germaine Odenheimer, MD (Co-Chair) (neurology)
François Boller, MD, PhD, FAAN (neurology)
Soo Borson, MD (geriatric psychiatry)
Charles A. Cefalu, MD, MS (geriatric medicine)
Mirean Coleman, MSW, LICSW, CT (social work)
Patricia C. Davis, MD, MBA, FACR (radiology)
Mary Ann Forciea, MD (internal/geriatric
medicine)
Elizabeth M. Galik, PhD, CRNP (nursing)
Laura N. Gitlin, PhD (occupational therapy)
Helen H. Kyomen, MD, MS (geriatric and adult
psychiatry)
Katie Maslow, MSW (patient advocacy
representative)
Haydee Muse, MD (health plan representative)
Bruce E. Robinson, MD, MPH (geriatric medicine)
Robert Paul Roca, MD, MPH, MBA (geriatric psychiatry)
Amy E. Sanders, MD (geriatric neurology)
Jason E. Schillerstrom, MD (geriatric psychiatry)
Joseph W. Shega, MD (geriatric medicine, hospice and
palliative medicine)
Eric G. Tangalos, MD, FACP, AGSF, CMD
(internal/geriatric medicine)
Joan M. Teno, MD, MS (internal medicine)
Brian K. Unwin, MD, FAAFP (family medicine)
John Robert Absher, MD (neurology) -- Liaison to American Academy of Neurology’s Quality Measurement
and Reporting Subcommittee
Work Group Staff
American Academy of Neurology
Gina K. Gjorvad
Rebecca J. Swain-Eng, MS
American Medical Directors Association
Jill S. Epstein, MA
Jacqueline Vance, RNC, CDONA/LTC
American Geriatrics Society
Caitlin Connolly
Susan Sherman
American Psychiatric Association
Robert M. Plovnick, MD, MS
American Medical Association (AMA)
Mark Antman, DDS, MBA
Christopher Carlucci, MBA
Victoria Fils, EdD, MPH
Kendra Hanley, MS
Karen Kmetik, PhD
Stephanie Moncada, MS
Pamela O’Neil, MPH
David Marc Small, MS, MPP
Samantha Tierney, MPH
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
4
Executive Summary:
Toward Improving Outcomes for Patients with Dementia
The American Academy of Neurology (AAN), American Geriatrics Society (AGS), American Medical Directors
Association (AMDA), American Psychiatric Association (APA), and Physician Consortium for Performance
Improvement® (PCPI™) formed a Dementia Work Group to identify and define quality measures toward
improving outcomes for patients with dementia (see diagram at the end of this section).
The Work Group focused on measures that would be applicable to patients with an established diagnosis of
dementia. As a result, the measures primarily target underemphasized aspects of the evaluation and
management of dementia patients.
Reasons for Prioritizing Improvement in Dementia
High Impact Topic Area
Dementia is a chronic condition that poses a major and growing threat to the public’s health. Improving the
effectiveness of care and optimizing patient outcomes will become increasingly important as the population of
the United States ages.

Dementia affects approximately 5%–8% of individuals over age 65 years, 15%–20% of individuals over age 75
years, and 25%–50% of individuals over age 85 years.1

Currently, an estimated 5.3 million Americans of all ages have Alzheimer’s disease – the most common form
of dementia.2

More than 20 percent of women and approximately 17 percent of men reaching the age of 65 would
ultimately develop dementia (estimated lifetime risk).2

Alzheimer’s disease was the sixth-leading cause of death across all ages in the United States in 2007.3 It was
the fifth-leading cause of death for those aged 65 and older in 2006.2

People with Alzheimer’s disease and other dementias have more than three times as many hospital stays as
other older people.2

At any one time, about one-quarter of all hospital patients aged 65 and older are people with Alzheimer’s
and other dementias.1

In 2009, almost 11 million family members, friends and neighbors provided 12.5 billion hours of unpaid care
for a person with Alzheimer’s disease or other dementias. This number represents an average of 21.9 hours
of care per caregiver per week, or 1,139 hours of care per caregiver per year.2

The total estimated worldwide costs of dementia are $604 billion in 2010, accounting for around 1% of the
world’s gross domestic product.4

In 2005, the direct costs to Medicare and Medicaid for care for people with Alzheimer’s and other dementias
and the estimated indirect costs to businesses for employees who were caregivers of people with
Alzheimer’s and other dementias amounted to more than $148 billion.1
Demonstrated Opportunity for Improvement

According to a study analyzing the quality of medical care provided to vulnerable community-dwelling older
patients, quality of care for geriatric conditions (eg, dementia, urinary incontinence) was found to be poorer
than care for general medical conditions (eg, diabetes, heart failure). On average, patients with dementia
received the recommended quality of care only about 35 percent of the time.5

Chodosh and colleagues found that current practice patterns indicate a significant opportunity for
improvement in the quality of dementia care with a majority (11 of 18) of guideline-recommended dementia
care processes having less than 40% adherence.6

Another study identified considerable variability across sites in the routine implementation of recommended
practices for the assessment, management and treatment of patients with dementia.7
Disparities

A recent systematic review and meta-analysis of the use of dementia treatment, care, and research identified
significant racial and ethnic disparities in western countries, particularly the United States. Overall, the
authors found “consistent evidence, mostly from the United States, that [minority ethnic] people accessed
diagnostic services later in their illness, and once they received a diagnosis, were less likely to access
antidementia medication, research trials, and 24-hour care.”8
Rigorous Clinical Evidence Base
Evidence-based clinical practice guidelines are available for the management of dementia. This measurement set
is based on guidelines from:

American Academy of Neurology

American Medical Directors Association

American Psychiatric Association
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
5
Executive Summary:
Toward Improving Outcomes for Patients with Dementia


California Workgroup on Guidelines for Alzheimer’s Disease Management
Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia
Dementia Outcomes
Ideally, a set of performance measures would include both measures of outcomes as well as measures of
processes that are known to positively influence desirable outcomes. The development of outcome measures for
dementia proved particularly challenging given the frequently progressive nature of the syndrome and the
paucity of interventions available to change its course. In light of these difficulties, the Work Group set out to
develop performance measures based on processes that are associated with desired outcomes and reflect high
quality care. Desired outcomes for dementia include:
1. Delay cognitive decline
2. Attain and maintain the highest practicable level of personal functioning
3. Decrease the severity and frequency of neuropsychiatric symptoms
4. Delay institutionalization of the patient
5. Promote caregiver and patient-centered decision-making
6. Reduce caregiver stress and burden
7. Enhance caregiver knowledge of and comfort with dementia care
Dementia Work Group Recommendations
Process measures: Several processes of care, demonstrated to improve outcomes for dementia patients, are
recommended:
Measures addressing underuse of effective services (evaluation and treatment strategies)
Measure #1: Staging of Dementia
Measure #2: Cognitive Assessment
Measure #3: Functional Status Assessment
Measure #4: Neuropsychiatric Symptom Assessment
Measure #5: Management of Neuropsychiatric Symptoms
Measure #6: Screening for Depressive Symptoms
Measures addressing safety
Measure #7: Counseling regarding Safety Concerns
Measure #8: Counseling regarding Risks of Driving
Measures addressing underuse of patient-centered care strategies
Measure #9: Palliative Care Counseling and Advance Care Planning
Measure #10: Caregiver Education and Support
These clinical performance measures are designed for practitioner level quality improvement to achieve better
outcomes for patients with dementia. Unless otherwise indicated, the measures are also appropriate for
accountability if the appropriate methodological, statistical, and implementation rules are achieved.
Other Potential Measures
The Work Group considered several other potential measures, though ultimately determined that they were not
appropriate for inclusion in the measure set.
Measure Harmonization
When existing hospital-level or plan-level measures are available for the same measurement topics, the PCPI
attempts to harmonize the measures to the extent feasible.
Technical Specifications Overview
There are several data sources available for collecting performance measures; generally different data sources
require different sets of measure specifications, due to the structure of the systems storing the data. The PCPI
recognizes that Electronic Health Records (EHRs) are the state of the art for clinical encounters and is focusing
significant resources and expertise toward specifying and testing measures within EHRs, as they hold the
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
6
Executive Summary:
Toward Improving Outcomes for Patients with Dementia
promise of providing the relevant clinical data for measures and for providing feedback to physicians and other
health care providers that is timely and actionable.
The PCPI develops technical specifications for multiple data sources, including:

EHR Data

Electronic Administrative Data (Claims)
o Prospective Claims-based reporting (using CPT Category II codes)
o Retrospective Claims Analysis

Expanded (multiple-source) Administrative Data

Paper Medical Record/Retrospective Data Collection Flow Sheet
Because administrative claims are currently available sources of data, specifications to collect and report on the
Dementia measures for administrative claims are included in this document. In light of recent national
initiatives to encourage physicians and other health care professionals to adopt EHRs in their practices, the PCPI
advocates that performance measures be integrated into EHR systems so that data for measurement and
improvement are part of the fabric of care. EHRs also may be the source for external reporting. One venue for
advancing this work is the AMA/National Committee for Quality Assurance (NCQA)/Healthcare Information and
Management Systems Society (HIMSS) Electronic Health Record Association (EHRA) Collaborative (see www.amaassn.org/go/collaborative).
Additional detailed information regarding PCPI Specifications Methodology, including measure exceptions, is
included in the Technical Specifications section of this document.
Testing and Implementation of the Measurement Set
The measures in the set are being made available without any prior testing. The PCPI will welcome the
opportunity to promote the initial testing of these measures and to ensure that any results available from testing
are used to refine the measures before implementation.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
7
Executive Summary:
Toward Improving Outcomes for Patients with Dementia
L i nk t o Ou t com e s:
The proposed measures focus on accurate and appropriate evaluation and monitoring of disease status and associated symptoms to guide treatment, effective
therapeutic options in eligible patients, enhancing patient safety and the avoidance of adverse events, increasing patient and caregiver awareness of advance planning,
and easing patient and caregiver burden by referring them to additional sources for support.
8
P ur p o se o f M e a su r e m e nt S e t :
The American Academy of Neurology (AAN), American Geriatrics Society (AGS), American Medical Directors
Association (AMDA), American Psychiatric Association (APA), and Physician Consortium for Performance
Improvement® (PCPI) formed a Dementia Work Group to identify and define quality measures toward improving
outcomes for patients with dementia. The Work Group aimed to develop a comprehensive set of measures that
support the efficient delivery of high quality health care in each of the Institute of Medicine’s (IOM) six aims for
quality improvement (safe, effective, patient centered, timely, efficient, and equitable).9
The Work Group was tasked with developing measures that reflect the most rigorous clinical evidence and
address areas most in need of performance improvement. The Work Group considered opportunities for
outcome, process and structural measures as well as composite, bundled and group or system-level measures.
The Work Group focused on measures that would be applicable to patients with an established diagnosis of
dementia. As a result, the measures primarily target underemphasized aspects of the evaluation and
management of dementia patients. Although the Work Group recognizes that diagnostic accuracy is the
prerequisite for optimal therapy10, it is beyond the scope of the measure set and difficult to operationalize in
performance measurement. The measures are developed and to be implemented based on the assumption that
diagnosis of dementia is accurate and was established in accordance with evidence-based diagnostic criteria.
Importance of Topic
Prevalence and Incidence:

Dementia affects approximately 5%–8% of individuals over age 65 years, 15%–20% of individuals over age 75
years, and 25%–50% of individuals over age 85 years.1

Alzheimer’s disease is the most common form of dementia, accounting for 60 to 80 percent of cases.1

One in eight persons aged 65 and older (13%) have Alzheimer’s disease.2

Currently, an estimated 5.3 million Americans of all ages have Alzheimer’s disease.2

The number of people aged 65 and older with Alzheimer’s disease is estimated to reach 7.7 million in 2030,
more than a 50 percent increase from current estimates. By 2050, the number of individuals aged 65 and
older with Alzheimer’s is projected to number between 11 million and 16 million.1

In 2000, there were an estimated 411,000 incident cases of Alzheimer’s disease. By 2010, that number is
expected to increase to 454,000 new cases per year; and by 2050, to 959,000.2

Every 70 seconds, someone in America develops Alzheimer’s disease. By mid-century, someone will develop
Alzheimer’s every 33 seconds.2

More than 20 percent of women reaching the age of 65 would ultimately develop dementia (estimated
lifetime risk), compared to approximately 17 percent of men.1

For women, at age 65, the short-term risk for developing dementia over the next 10 years is approximately 1
percent. However, at age 75, for women, the risk of developing dementia over the next 10 years jumps more
than sevenfold, and at 85, the risk skyrockets to 20-fold. The risk scenario for men follows a similar
trajectory.1
Mortality:

Alzheimer’s disease was the sixth-leading cause of death across all ages in the United States in 2007.3 It was
the fifth-leading cause of death for those aged 65 and older in 2006.2

While the total number of deaths attributed to other major causes of deaths has been decreasing, those due
to Alzheimer’s have continued to increase. Comparing changes in selected causes of death between 2000
and 2006, deaths attributed to Alzheimer’s disease increased 47.1 percent, while those attributed to the
number one cause of death, heart disease, decreased 11.5 percent.1

A study of national death certificates for 2001 found that 66.9 percent of people aged 65 and older who
died of dementia did so in nursing homes. In contrast, 20.6 percent of patients dying from cancer died in
nursing homes. Among those dying of other conditions, 28 percent died in nursing homes.1
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
9

Median survival time for outpatients with Alzheimer’s disease has been found to be largely dependent on
age of onset with estimates ranging from 3.3 to 9.3 years.1
Use of Health Care Resources:

People with Alzheimer’s disease and other dementias have more than three times as many hospital stays as
other older people.2

At any one time, about one-quarter of all hospital patients aged 65 and older are people with Alzheimer’s
and other dementias.1

In 2004, Medicare beneficiaries aged 65 and older with Alzheimer’s and other dementias were eight times
more likely than other Medicare beneficiaries in the same age group to have a Medicare-covered stay in a
skilled nursing facility (SNF).12

In 2004, one-quarter of Medicare beneficiaries aged 65 and older who received Medicare-covered home
health care services were people with Alzheimer’s and other dementias, about twice as many as one would
expect given the proportion of Medicare beneficiaries with Alzheimer’s and other dementias among all
Medicare beneficiaries.12
Family Caregiving:

The vast majority (87%) of individuals with Alzheimer’s disease are cared for at home by family members.1

In 2009, almost 11 million family members, friends and neighbors provided 12.5 billion hours of unpaid
care for a person with Alzheimer’s disease or other dementias. This number represents an average of 21.9
hours of care per caregiver per week, or 1,139 hours of care per caregiver per year.2
Cost:

The total estimated worldwide costs of dementia are $604 billion in 2010, accounting for around 1% of the
world’s gross domestic product.4
About 70% of the worldwide costs occur in Western Europe and North America.4
Researchers tentatively estimated an 85% increase in worldwide costs by 2030 (exceeding $1 trillion),
based only on predicted increases in the numbers of people with dementia.4

In 2005, the direct costs to Medicare and Medicaid for care for people with Alzheimer’s and other dementias
and the estimated indirect costs to businesses for employees who were caregivers of people with
Alzheimer’s and other dementias amounted to more than $148 billion, including:
$91 billion in Medicare costs for care of beneficiaries with Alzheimer’s and other dementias.1
$21 billion in state and federal Medicaid costs for nursing home care for people with Alzheimer’s and
other dementias.1
$36.5 billion in indirect costs to business for employees who are caregivers of people with Alzheimer’s
and other dementias, calculated for 2002 and projected to 2005.1

In 2009, the economic value of the care provided by family and other unpaid caregivers of people with
Alzheimer’s and other dementias was $144 billion.2
Opport unit y for Im prov eme nt

According to a study analyzing the quality of medical care provided to vulnerable community-dwelling older
patients, quality of care for geriatric conditions (eg, dementia, urinary incontinence) was found to be poorer
than care for general medical conditions (eg, diabetes, heart failure). On average, patients with dementia
received the recommended quality of care only about 35 percent of the time. Vulnerable elders, identified
by a 13-item function-based screening survey, are community-dwelling persons 65 years of age and older
who have 4 times the risk for functional decline or death over the next 2 years compared with individuals
not identified as vulnerable. Quality of care was assessed by clinician performance on nine dementia quality
indicators. Quality of care varied significantly by indicator with average rates of adherence ranging from
18% for an assessment of functional status upon admission to a hospital or a new visit to a physician
practice (n=130) to 100% for the offering of appropriate stroke prophylaxis for a dementia patient who also
has cerebrovascular disease (n=2).5

Chodosh and colleagues aimed to characterize contemporary care patterns for dementia within one U.S.
metropolitan area by analyzing medical records and caregiver surveys for 378 patients. To quantify quality
of care, 18 dementia care processes drawn from existing guidelines were assessed. These care processes
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
10
were aggregated within four care dimensions: assessment (6 processes), treatment (6 processes), education
and support (3 processes), and safety (3 processes). Adherence to the 18 individual care processes ranged
from 9% to 79%; notably 11 of 18 care processes had less than 40% adherence.6

A study surveying clinicians practicing in 6 VA medical centers aimed to asses the extent to which providers
are following dementia practice guidelines. The investigators identified considerable variability across sites
in the routine implementation of recommended practices for the assessment, management and treatment of
patients with dementia. Practices for which adherence to clinical practice guidelines was moderate to low
included cognitive and depression screening, reporting of elder abuse, discussing care needs and decisionmaking issues with patients’ family and implementing caregiver support practices.7
Disparities
A recent systematic review and meta-analysis of the use of dementia treatment, care, and research identified
significant racial and ethnic disparities in western countries, particularly the United States. Overall, the authors
found “consistent evidence, mostly from the United States, that [minority ethnic] people accessed diagnostic
services later in their illness, and once they received a diagnosis, were less likely to access antidementia
medication, research trials, and 24-hour care.”8
 Non-Hispanic Blacks with dementia are more likely to be undiagnosed or misdiagnosed relative to nonHispanic Whites.”11,12
 Anti-dementia medication use was approximately 30% higher among non-Hispanic Whites compared to other
racial/ethnic groups, after adjusting for demographics, socioeconomics, health care access and utilization,
comorbidities, and service year.13
 “Both non-Hispanic Blacks and Latinos transition to long-term care at more advanced stages of dementia.”14,15
 Minority ethnic people with dementia were found to be 40% less likely to enter 24-hour care. This may be due
to choice, cultural preferences or barriers to access8
The PCPI believes that performance measure data should be stratified by race, ethnicity, and primary written
and spoken language to assess disparities and initiate subsequent quality improvement activities addressing
identified disparities. These categories are consistent with recent national efforts to standardize the collection
of race and ethnicity data. A 2008 National Quality Forum (NQF) report endorsed 45 practices including
stratification by the aforementioned variables.16 A 2009 Institute of Medicine (IOM) report “recommends
collection of the existing Office of Management and Budget (OMB) race and Hispanic ethnicity categories as well
as more fine-grained categories of ethnicity (referred to as granular ethnicity and based on one’s ancestry) and
language need (a rating of spoken English language proficiency of less than very well and one’s preferred
language for health-related encounters).”17
C l i ni ca l Ev i d e nce B a se
Clinical practice guidelines serve as the foundation for the development of performance measures. A number of
clinical practice guidelines have been developed for dementia and Alzheimer’s disease, offering a robust
evidence base to guide clinical decision-making and performance measure development. Guidelines from the
American Academy of Neurology18,19,20, American Psychiatric Association21, American Medical Directors
Association22, Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia23, and a work
group that included the Los Angeles chapter of the Alzheimer’s Association24 were reviewed during the measure
development process. Additional recommendations from the American Geriatrics Society, American College of
Physicians and other groups that focused on specific dimensions in the care of patients with dementia were also
considered.
Relevant guidelines met all of the required elements and many, if not all, of the preferred elements outlined in a
PCPI position statement establishing a framework for consistent and objective selection of clinical practice
guidelines from which PCPI Work Groups may derive clinical performance measures.25
Performance measures, however, are not clinical practice guidelines and cannot capture the full spectrum of
care for all patients with dementia. The guideline principles with the strongest recommendations and often the
highest level of evidence (well-designed randomized-controlled trials) served as the basis for measures in this
set.
Dementia Outcomes
Ideally, a set of performance measures would include both measures of outcomes as well as measures of
processes that are known to positively influence desirable outcomes. The development of outcome measures
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
11
for dementia proved particularly challenging given the frequently progressive nature of the syndrome.
Additionally, there are no existing interventions to halt progression with current pharmacologic and nonpharmacologic interventions showing only modest improvements, or a slower decline, in cognition and function
in a substantial minority of patients.21 The goals of management, particularly for those patients with advanced
cognitive impairment, are often focused on improving the quality of life for patients and caregivers, maintaining
optimal function and providing maximum comfort.26 In light of these difficulties, the Work Group set out to
identify the desired outcomes for dementia with a goal of developing performance measures based on processes
that are associated with desired outcomes and reflect high quality care. Desired outcomes for dementia include:
1. Delay cognitive decline
2. Attain and maintain the highest practicable level of personal functioning
3. Decrease the severity and frequency of neuropsychiatric symptoms
4. Delay institutionalization of the patient
5. Promote caregiver and patient-centered decision-making
6. Reduce caregiver stress and burden
7. Enhance caregiver involvement and comfort with dementia care
I nte nde d A u die nc e, Ca re Se tti ng, a nd P a t ie nt P o pu l at i o n
The PCPI encourages use of these measures by physicians and other health care professionals, where
appropriate, to manage the care for all patients with dementia, regardless of age.
Dementia Work G rou p Recommendations
The measurement set includes measures that focus on accurate and appropriate evaluation and monitoring of
disease status and associated symptoms to guide treatment, effective therapeutic options in eligible patients,
enhancing patient safety and the avoidance of adverse events, increasing patient and caregiver awareness of
advance planning, and easing patient and caregiver burden by referring them to additional sources for support.
The Dementia Work Group identified several desired outcomes for patients with dementia (see “Link to
Outcomes” diagram in preceding section). Current quality gaps in dementia care emphasize the need to
improve specific processes that have been demonstrated to improve dementia outcomes (ie, the assessment and
monitoring of patients throughout the disease course, safety interventions, and the provision/referral of
education and support for caregivers). As a result, many of the measures in the dementia set focus on the
provision of effective and patient-centered care.
These clinical performance measures are designed for practitioner level quality improvement to achieve better
outcomes for patients with dementia. Unless otherwise indicated, the measures are also appropriate for
accountability if the appropriate methodological, statistical, and implementation rules are achieved.
The measures listed below may be used for quality improvement and accountability.
Measures addressing underuse of effective services (evaluation and treatment strategies)
Measure #1: Staging of Dementia
Measure #2: Cognitive Assessment
Measure #3: Functional Status Assessment
Measure #4: Neuropsychiatric Symptom Assessment
Measure #5: Management of Neuropsychiatric Symptoms
Measure #6: Screening for Depressive Symptoms
Measures addressing safety
Measure #7: Counseling regarding Safety Concerns
Measure #8: Counseling regarding Risks of Driving
Measures addressing underuse of patient-centered care strategies
Measure #9: Palliative Care Counseling and Advance Care Planning
Measure #10: Caregiver Education and Support
Given the continued and progressive impairment in cognition and function over time for dementia patients,
family members and other individuals play a pivotal role in care management. We have used the following
terms and corresponding definitions throughout the document to describe these individuals. The terms are not
mutually exclusive.
Caregivers: “Persons who provide care to those who need supervision or assistance in illness or disability. They
may provide the care in the home, in a hospital, or in an institution. Although caregivers include trained
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
12
medical, nursing, and other health personnel, the concept also refers to parents, spouses, or other family
members, friends, members of the clergy, teachers, social workers, fellow patients.”27
Knowledgeable Informants: Knowledgeable informants know and have frequent contact with the patient.28
These measures support the efficient delivery of high quality health care in many of the IOM’s six aims for
quality improvement9 as described in the following table:
IOM Domains of Health Care Quality
Safe
Effective
PatientTimely
Efficient
Equitable
Underuse
Overuse
centered
Measures
1
2
3
4
5
6
7
8
9
10
Staging of Dementia
Cognitive Assessment
Functional Status Assessment
Neuropsychiatric Symptom
Assessment
Management of Neuropsychiatric
Symptoms
Screening for Depressive
Symptoms
Counseling Regarding Safety
Concerns
Counseling regarding Risks of
Driving
Palliative Care Counseling and
Advance Care Planning
Caregiver Education and Support
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
O t he r P ote nt i al M ea su r e s
The Work Group considered several other important constructs in dementia care, though ultimately determined
that they were not appropriate as the subject of performance measures. In particular, there was universal
agreement among Work Group members that one of the largest problems in dementia care is the inadequate
recognition of dementia in clinical practice. Research has shown that a small minority (anywhere between 1235%) of patients with dementia, Alzheimer’s disease, or cognitive impairment had a diagnosis of the condition in
their medical record.29,30,31,32,33 Another study concluded that only 41% of the subjects determined to have
dementia by the researchers were recognized as having cognitive impairment by their primary care physician
based on a notation in their medical record of any of three things (any cognitive diagnosis, prescription of an
anti-dementia medication, and/or a notation that the physician had administered a mental status test and stated
that the person’s score was abnormal).34 The identification and detection of dementia clearly represents a
significant opportunity for improvement and is vital as the gateway to initiation and engagement in treatment.
Despite its importance and the availability of several reliable and valid case detection tools, a number of
national and international organizations have stopped short of recommending routine screening for dementia in
older adults. However, many of these organizations “did recommend a diagnostic evaluation when memory
problems or dementia were suspected.”35 Given the lack of evidence to support routine screening and the
inherent difficulty in identifying the population of patients for whom dementia screening is recommended, the
Work Group felt that it was premature to move forward with the development of a measure that could address
this well documented gap in care.
The Work Group considered including the use of cholinesterase inhibitors (CEIs) as a treatment-related
performance measure for patients with Alzheimer’s disease or other dementias. While the use of these agents
has demonstrated modest improvements in cognition and global assessments in a substantial minority of
patients, “uncertainty persists about the clinical relevance of these outcomes (which are not used in routine
clinical practice) and the duration of the apparent benefit (the randomized controlled trials reviewed were 12 to
52 weeks in duration, and all but one was 26 weeks or less).”36 Although clinical practice guidelines have
appropriately recommended that cholinesterase inhibitors be considered for all patients with mild to moderate
Alzheimer’s disease, they have also emphasized the need to base the decision to initiate pharmacotherapy with
these agents on individualized assessment after a thorough discussion of their benefits and risks. As a result,
the Work Group felt that it would be premature to establish the use of CEIs as a performance measure at this
time.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
13
While each performance measure is intended to support quality improvement in one or more of the IOM
domains (safe, effective, patient centered, timely, efficient, and equitable), the development of measures
specifically designed to eliminate overuse of ineffective care and promote efficiency proved more challenging.
One significant area of overuse in dementia care includes the use of aggressive and ineffective treatment at the
end of life. Given the complexity of these issues and the importance of eliciting and adhering to patient
preference, there is no generalizable way to identify patients who may be subject to this overuse. As a result,
the direct assessment of these care processes was not feasible within the constructs of performance
measurement. Nevertheless, measure #9 in this set may indirectly address these significant concerns in the care
of patients with dementia.
M ea su r e H a rmo ni z a t io n
When existing hospital-level or plan-level measures are available for the same measurement topics, the PCPI
attempts to harmonize the measures to the extent feasible. Apart from the 2001 work of RAND to identify
quality indicators for dementia as part of the Assessing Care of Vulnerable Elderly (ACOVE) project37, there
remains a paucity of measures to address the quality of dementia care. The ACOVE indicators were reviewed
during the measure development process and harmonization was considered, where appropriate.
T e c hnic a l S pe c i f i ca t i o n s O v e r v ie w
There are several data sources available for collecting performance measures; generally different data sources
require different sets of measure specifications, due to the structure of the systems storing the data. The PCPI
recognizes that EHRs are the state of the art for clinical encounters and is focusing significant resources and
expertise toward specifying and testing measures within EHRs, as they hold the promise of providing the
relevant clinical data for measures and for providing feedback to physicians and other health care providers that
is timely and actionable.
The PCPI develops technical specifications for multiple data sources, including:

EHR Data

Electronic Administrative Data (Claims)
o Prospective Claims-based reporting (using CPT Category II codes)
o Retrospective Claims Analysis

Expanded (multiple-source) Administrative Data

Paper Medical Record/Retrospective Data Collection Flow Sheet
Because administrative claims are currently available sources of data, specifications to collect and report on the
Dementia measures for administrative claims are included in this document. In light of recent national
initiatives to encourage physicians and other health care professionals to adopt EHRs in their practices, the PCPI
advocates that performance measures be integrated into EHR systems so that data for measurement and
improvement are part of the fabric of care. EHRs also may be the source for external reporting. One venue for
advancing this work is the AMA/NCQA/HIMSS Electronic Health Record Association (EHRA) Collaborative (see
www.ama-assn.org/go/collaborative).
Additional detailed information regarding PCPI Specifications Methodology, including measure exceptions, is
included in the Technical Specifications section of this document.
T e st i ng and I m pl eme nt at io n o f t he Mea su r e m e nt S et
The measures in the set are being made available without any prior testing. The PCPI recognizes the importance
of testing all of its measures and encourages testing of the Dementia measurement set for feasibility and
reliability by organizations or individuals positioned to do so. The Measure Testing Protocol for PCPI Measures
was approved by the PCPI in 2007 and is available on the PCPI web site (see Position Papers at
www.physicianconsortium.org); interested parties are encouraged to review this document and to contact PCPI
staff. The PCPI will welcome the opportunity to promote the initial testing of these measures and to ensure that
any results available from testing are used to refine the measures before implementation.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
14
Measure #1: Staging of Dementia
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia whose severity of dementia was classified
as mild, moderate or severe at least once within a 12 month period
Measure Components
Numerator
Statement
Patients whose severity of dementia was classified* as mild, moderate or severe** at least
once within a 12 month period
*Dementia severity can be assessed using one of a number of available valid and reliable
instruments available from the medical literature. Examples include, but are not limited
to:

Global Deterioration Scale (GDS)

Functional Assessment Staging Tool (FAST)

Clinical Dementia Rating (CDR)

Dementia Severity Rating Scale

Mini-Mental State Examination (MMSE) [Note: While simple and quick to administer, the
MMSE is best suited for screening purposes and is therefore at best a blunt instrument
for staging Alzheimer’s disease. The MMSE has not been well validated for nonAlzheimer’s dementias.]

Formal Neuropsychological Evaluation
**Mild dementia can be classified quantitatively as MMSE score of >18, GDS or FAST stage
4, CDR of 1; qualitatively as being likely to have difficulty with balancing a checkbook,
preparing a complex meal, or managing a complicated medication schedule
Moderate dementia can be classified quantitatively as MMSE score of 10–18, GDS or FAST
stages 5 and 6, CDR of 2; qualitatively as experiencing difficulties with simpler food
preparation, household cleanup, and yard work and requiring assistance with some
aspects of self-care (eg, picking out the proper clothing to wear)
Severe dementia can be classified quantitatively as MMSE score of <10, GDS or FAST stages
6 and 7, CDR of 3; qualitatively as requiring considerable or total assistance with personal
care, such as dressing, bathing, and toileting.21
Note: The proposed scoring cut-offs listed above are offered only as a guide and are quoted
verbatim from the referenced clinical guideline. The scoring and appropriate severity cutoffs for ANY of these instruments must be interpreted in the context of the patient’s age,
education, and ethnicity.
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
None
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
Progressive dementias are generally staged globally according to the level of cognitive and
functional impairment, and the same categories may be used to describe the degree of
severity of any dementia. However, the staging criteria have not been well validated for
non-Alzheimer’s dementias. Specific functional staging (FAST staging) has also been
developed, is widely used, and can be very useful in tracking the course of Alzheimer’s
disease and other dementias… The CDR is a commonly used scale to stage dementia
Severity…The Global Deterioration Scale (GDS) distinguishes three stages in this range.
(APA, 2007)21
Individuals with “mild” dementia (MMSE score of >18, GDS or FAST stage 4, CDR of 1) are
likely to have difficulties with balancing a checkbook, preparing a complex meal, or
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
15
managing a difficult medication schedule. Those with “moderate” impairment (MMSE score
of 10–18, GDS or FAST stages 5 and 6, CDR of 2) also have difficulties with simpler food
preparation, household cleanup, and yard work and may require assistance with some
aspects of self-care (e.g., picking out the proper clothing to wear). Those whose dementia
is “severe” (MMSE score of <10, GDS or FAST stages 6 and 7, CDR of 3) require
considerable or total assistance with personal care, such as dressing, bathing, and
toileting. Research has shown that measurable cognitive abilities remain throughout the
course of severe dementia. In the terminal phase, patients become bed bound, develop
contractures, require constant care, and may be susceptible to accidents and infectious
diseases, which ultimately prove fatal. (APA, 2007)21
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Dementia is characterized by continued and progressive impairment in cognition and
function including the evolution of symptoms over time.21 The treatment varies throughout
the disease course.21 Patients with dementia, therefore, require assessment of disease
severity and subsequent treatment specific and appropriate to their current stage of
disease.21 Early stage patients, for example, have special needs and can and should be
involved in care planning and referred to community resources.24 Care for late stage
patients may focus on improving the quality of life for patients and caregivers, maintaining
optimal function and providing maximum comfort.26
Assessing a patient’s stage of dementia involves an evaluation of their cognitive and
functional status. A 2007 analysis of medical records and caregiver surveys for 378
patients with dementia found that 50% of patients received an assessment of their
cognitive status and only 9.5% received an assessment of their activities of daily living in
the previous 12 months.6 Similar results were reported in a study analyzing the quality of
health care provided to a broader population of vulnerable community-dwelling older
patients. Of vulnerable elders admitted to a hospital or new to a physician practice, 52%
had documentation of a multidimensional assessment of cognitive ability while only 18%
received an assessment of their functional status.5 Another study surveying clinicians
practicing in VA medical centers found that only two thirds of clinicians reported regularly
performing a standardized assessment of cognitive functioning.7
 Equitable
 Effective
 Patient-centered
This measure has no exceptions.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
16
Measure #2: Cognitive Assessment
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is
performed and the results reviewed at least within a 12 month period
Measure Components
Numerator
Statement
Patients for whom an assessment of cognition is performed and the results reviewed at
least once within a 12 month period
*Cognition can be assessed by direct examination of the patient using one of a number of
instruments, including several originally developed and validated for screening purposes.
This can also include, where appropriate, administration to a knowledgeable informant.
Examples include, but are not limited to:

Blessed Orientation-Memory-Concentration Test (BOMC)

Mini-Cog

Montreal Cognitive Assessment (MoCA)

Cognitive Abilities Screening Instrument (CASI)

St. Louis University Mental Status Examination (SLUMS)

Mini-Mental State Examination (MMSE) [Note: The MMSE has not been well validated for
non-Alzheimer’s dementias.

Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE)

Ascertain Dementia 8 (AD8) Questionnaire

Minimum Data Set (MDS) Brief Interview of Mental Status (BIMS) [Note: Validated for
use with nursing home patients only]

Formal neuropsychological evaluation
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
Documentation of medical reason(s) for not assessing cognition (eg, patient with very
advanced stage dementia, other medical reason)
Documentation of patient reason(s) for not assessing cognition
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
Ongoing assessment includes periodic monitoring of the development and evolution of
cognitive and noncognitive psychiatric symptoms and their response to intervention
(Category I). Both cognitive and noncognitive neuropsychiatric and behavioral symptoms
of dementia tend to evolve over time, so regular monitoring allows detection of new
symptoms and adaptation of treatment strategies to current needs…Cognitive symptoms
that almost always require assessment include impairments in memory, executive
function, language, judgment, and spatial abilities. It is often helpful to track cognitive
status with a structured simple examination. (APA, 2007)21
Conduct and document an assessment and monitor changes in cognitive status using a
reliable and valid instrument. Cognitive status should be reassessed periodically to
identify sudden changes, as well as to monitor the potential beneficial or harmful effects
of environmental changes, specific medications, or other interventions. Proper assessment
requires the use of a standardized, objective instrument that is relatively easy to use,
reliable (with less variability between different assessors), and valid (results that would be
similar to gold-standard evaluations). (California Workgroup on Guidelines for
Alzheimer’s Disease Management, 2008)24
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
17
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Dementia is often characterized by the gradual onset and continuing cognitive decline in
one or more domains including memory, executive function, language, judgment, and
spatial abilities.21 Cognitive deterioration represents a major source of morbidity and
mortality and poses a significant burden on affected individuals and their caregivers.38
Although cognitive deterioration follows a different course depending on the type of
dementia, significant rates of decline have been reported. For example, one study found
that the annual rate of decline for Alzheimer’s disease patients was more than four times
that of older adults with no cognitive impairment.39 Nevertheless, measurable cognitive
abilities remain throughout the course of dementia.21 Initial and ongoing assessments of
cognition are fundamental to the proper management of patients with dementia. These
assessments serve as the basis for identifying treatment goals, developing a treatment plan,
monitoring the effects of treatment, and modifying treatment as appropriate.
A 2007 analysis of medical records and caregiver surveys for 378 patients with dementia
found that only 50% of patients received an assessment of their cognitive status in the
previous 12 months.6 Another study surveying clinicians practicing in VA medical centers
found that only two thirds of clinicians reported regularly performing a standardized
assessment of cognitive functioning.7
 Effective
 Equitable
 Patient-centered
A medical reason exception has been included so that clinicians can exclude patients for
whom a cognitive assessment may not be appropriate (eg, patients at the end of life). A
patient reason exception has been included for patients who might be unwilling to
participate in the assessment.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
18
Measure #3: Functional Status Assessment
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional
status is performed and the results reviewed at least once within a 12 month period
Measure Components
Numerator
Statement
Patients for whom an assessment of functional status* is performed and the results
reviewed at least once within a 12 month period
* Functional status can be assessed by direct examination of the patient or knowledgeable
informant. An assessment of functional status should include, at a minimum, an
evaluation of the patient’s ability to perform instrumental activities of daily living (IADL)
and basic activities of daily living (ADL). Functional status can also be assessed using one
of a number of available valid and reliable instruments available from the medical
literature. Examples include, but are not limited to:

Lawton IADL Scale

Barthel ADL Index

Katz Index of Independence in ADL
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
Documentation of medical reason(s) for not assessing functional status (eg, patient is
severely impaired and caregiver knowledge is limited, other medical reason)
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
A detailed assessment of functional status may also aid the clinician in documenting and
tracking changes over time as well as providing guidance to the patient and caregivers.
Functional status is typically described in terms of the patient’s ability to perform
instrumental activities of daily living such as shopping, writing checks, basic housework,
and activities of daily living such as dressing, bathing, feeding, transferring, and
maintaining continence. These regular assessments of recent cognitive and functional
status provide a baseline for assessing the effect of any intervention, and they improve the
recognition and treatment of acute problems, such as delirium. (APA, 2007)21
Conduct and document an assessment and monitor changes in daily functioning,
including feeding, bathing, dressing, mobility, toileting, continence, and ability to manage
finances and medications…Functional assessment includes evaluation of physical,
psychological, and socioeconomic domains. Physical functioning may focus
on basic activities of daily living (ADLs) that include feeding, bathing, dressing, mobility,
and toileting. Assessment of instrumental (or intermediate) activities of daily living
(IADLs) addresses more advanced self-care activities, such as shopping, cooking, and
managing finances and medications. Standardized assessment instruments such as the
Barthel or Katz indices can provide information on the patient’s capacity for self-care
and independent living. Proxies or patient surrogates can complete a number of these
instruments when necessary. The initial assessment of functional abilities is important to
determine a baseline to which future functional deficits may be compared. (California
Workgroup on Guidelines for Alzheimer’s Disease Management, 2008)24
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
19
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Dementia is characterized by cognitive deficits that cause functional impairment
compromising basic and instrumental activities of daily living. Functional decline for
dementia patients is progressive and continuous and typically marked by decline in
instrumental activities of daily living followed by a slower decline in basic activities of daily
living.40 Functional impairment is the main factor negatively impacting quality of life in
patients with dementia including reported links to the development of apathy and
depression.41,42,43 In addition, decline in basic activities of daily living is an important risk
factor for institutionalization and a strong predictor of decreased survival in dementia
patients.44,45 Initial and ongoing assessments of functional status should be conducted to
determine baseline level of functioning, monitor changes over time, and to identify
strategies to maximize patient’s independence.
A 2007 analysis of medical records and caregiver surveys for 378 patients with dementia
found that only 9.5% of patients received an assessment of their activities of daily living in
the previous 12 months.6 Similar results were reported in a study analyzing the quality of
health care provided to a broader population of vulnerable community-dwelling older
patients. Only 18% of vulnerable elders admitted to a hospital or new to a physician
practice received an assessment of their functional status.5
 Equitable
 Effective
 Patient-centered
A medical reason exception has been included so that clinicians can exclude patients for
whom a functional assessment may not be feasible (eg, severely impaired patients whose
caregiver knowledge is limited).
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
20
Measure #4: Neuropsychiatric Symptom Assessment
Dementia
This measure is paired with Measure #5 – Management of Neuropsychiatric Symptoms
Implementers of this measure should not use Measure #4 without Measure #5.
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of
neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period
Measure Components
Numerator
Statement
Patients for whom an assessment of neuropsychiatric symptoms** is performed and
results reviewed at least once in a 12 month period
** Neuropsychiatric symptoms can be assessed by direct examination of the patient or
knowledgeable informant. The following is a non-exhaustive list of dimensions (based on
items included in available validated instruments) that may be evaluated during an
assessment of neuropsychiatric symptoms:
Activity disturbances:
o agitation
o wandering
o purposeless hyperactivity
o verbal or physical aggressiveness
o resistiveness with care
o apathy
o impulsiveness
o socially inappropriate behaviors
o appetite
o eating disturbances
o sleep problems
o diurnal/sleep-wake cycle disturbances
o repetitive behavior
Mood disturbances:
o anxiety
o dysphoria
o euphoria
o irritability
o mood lability/fluctuations
Thought and perceptual disturbances:
o having fixed false beliefs (delusions)
o hearing or seeing non-present entities (hallucinations)
o paranoia
Examples of reliable and valid instruments that are commonly used in research settings
and that can be used to assess behavior include, but are not limited to:

Dementia Signs and Symptoms (DSS) Scale46

Neuropsychiatric Inventory47 (NPI)
The assessment of behavioral status may include the assessment of Behavioral and
Psychological Symptoms of Dementia (BPSD)48. For patients residing in nursing homes, it
may include an assessment of the behavioral symptom items from the Minimum Data Set
(MDS).
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
None
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
21
Exceptions
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
It is important for the [clinician] treating a patient with dementia to regularly assess
cognitive deficits or behavioral difficulties that potentially pose a danger to the patient or
others. (APA, 2007)21
Conduct and document an assessment and monitor changes in behavioral symptoms,
psychotic symptoms, or depression. (California Workgroup on Guidelines for Alzheimer’s
Disease Management, 2008)24
For mild to moderate Alzheimer's disease
Assessment of patients with mild to moderate AD [Alzheimer’s Disease] should include
measures of behavior and other neuropsychiatric symptoms. (Grade B, Level 3) (Third
Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, 2008)36
For severe Alzheimer's disease
Assessment should include cognition (e.g., MMSE), function, behaviour, medical status,
nutrition, safety and caregiver health. (Grade B, Level 3) (Third Canadian Consensus
Conference on the Diagnosis and Treatment of Dementia, 2008)26
M ea su r e I m por ta nc e
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Neuropsychiatric symptoms appear to be common for patients with dementia. In
community samples of dementia patients, the prevalence of neuropsychiatric symptoms
range from 40-88%.49,50,51 Neuropsychiatric symptoms are also common in long-term care
facilities, with prevalence ranges from 80-85%.52,53 Neuropsychiatric symptoms of dementia
have been associated with accelerated cognitive decline;54 increased functional
impairment;55 decreased mean survival time;47 increased co-morbid conditions;56 increased
danger to self;48 increased danger to others;57 increased health care service utilization;48, 58, 59
higher risk for institutionalization;60, 61 and greater caregiver stress and burden.62, 63, 64
An assessment of neuropsychiatric symptoms, therefore, is an important step in the
development of a management plan for those with dementia.
In one analysis of medical records and caregiver surveys for 378 patients with dementia, it
was found that within a 12 month period only 73% of patients received an assessment of
behavioral problems or depression.6


Efficient
Equitable
This measure has no exceptions.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality Improvement
Accountability
Process
Individual practitioner




Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
22
 Administrative Data/Claims Expanded (multiple-source)
 Paper medical record
Additional Information
Measure #4 is paired with Measure #5 (Management of Neuropsychiatric Symptoms). The pairing of these
measures is not intended to suggest the use of any particular scoring methodology (ie, a composite score), nor
does it imply either equality of or difference in the relative “weights” of the two measures. A performance
score for each measure should be reported individually to provide actionable information upon which to
focus quality improvement efforts.
The NQF provides definitions of paired and composite measures65:

Paired measures are individual measures that should be measured concurrently in the same population;
however, the results are not combined into a single score (eg, measuring mortality and readmission and
displaying them together—but not calculating a joint score)

A composite measure is a combination of two or more individual measures in a single measure that results
in a single score.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
23
Measure #5: Management of
Neuropsychiatric Symptoms
Dementia
This measure is paired with Measure #4 – Neuropsychiatric Symptom Assessment.
Implementers of this measure should not use Measure #5 without Measure #4.
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia who have one or more neuropsychiatric
symptoms who received or were recommended to receive an intervention for neuropsychiatric symptoms within
a 12 month period
Measure Components
Numerator
Statement
Patients who received or were recommended to receive an intervention for
neuropsychiatric symptoms within a 12 month period
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia who have one or more
neuropsychiatric symptoms
Denominator
Exceptions
None
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
For mild to moderate Alzheimer's disease
The management of BPSD [Behavioral and Psychological Symptoms of Dementia] should
include a careful documentation of behaviours and identification of target symptoms, a
search for potential triggers or precipitants, recording of the consequences of the
behaviour, an evaluation to rule out treatable or contributory causes, and consideration of
the safety of the patient, their caregiver, and others in their environment.
(Grade B, Level 3) (Third Canadian Consensus Conference on the Diagnosis and Treatment
of Dementia, 2008)36
For severe Alzheimer's disease
The management of BPSD should begin with appropriate assessments, diagnosis, and
identification of target symptoms and consideration of safety of the patient, their
caregiver and others in their environment. (Grade B, Level 3) (Third Canadian Consensus
Conference on the Diagnosis and Treatment of Dementia, 2008)26
There are no fully comprehensive consensus guidelines for use of specific nonpharmacological approaches to neuropsychiatric symptoms. Patient heterogeneity,
variations in care settings, and the broad range of non-pharmacological interventions
having some empirical support impede uniform generalization. However, the following
evidence statements serve as the evidence to support the measure and are quoted verbatim
from the referenced clinical guidelines:
Nonpharmacologic interventions should be initiated first. Approaches that may be useful
for severe Alzheimer disease include behavioural management for depression, and
education programs for caregivers and staff to teach them how to recognize behavioural
problems and to teach them behaviour-modification techniques. Music therapy and
controlled multisensory stimulation (Snoezelen) are useful during treatment sessions, but
longer-term benefits have not been demonstrated (grade B recommendation, level 1
evidence). (Third Canadian Consensus Conference on the Diagnosis and Treatment of
Dementia, 2008)26
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
24
Except for emergency situations, non-pharmacological strategies are the preferred
first-line treatment approach for behavioral problems. Medications should be used only
as a last resort, if non-pharmacological approaches prove unsuccessful and they are
clinically indicated. (California Workgroup on Guidelines for Alzheimer’s Disease
Management, 2008)24
Pharmacologic therapies should be initiated concurrently with nonpharmacologic
interventions in the presence of severe depression, psychosis or aggression that puts the
patient or others at risk of harm (grade B recommendation, level 3 evidence). (Third
Canadian Consensus Conference on the Diagnosis and Treatment of Dementia, 2008)26
Measure Importance
Relationship to
desired
outcome
Neuropsychiatric symptoms are common in patients with dementia. In community samples
of dementia patients, the prevalence of neuropsychiatric symptoms ranges from 4088%.49,50,51 Neuropsychiatric symptoms are also common in long-term care facilities, with
prevalence ranges from 80-85%.52,53 Neuropsychiatric symptoms of dementia have been
associated with accelerated cognitive decline;54 increased functional impairment;55
decreased mean survival time;47 increased co-morbid conditions;56 increased danger to self;48
increased danger to others;57 increased health care service utilization;48,58,59 higher risk for
institutionalization;60,61 and greater caregiver stress and burden.62, 63, 64
Nonpharmacologic interventions should be considered in all cases and in some will be the
mainstay of management. Examples of approaches that may be useful include behavioural
management for depression, education programs for caregivers and staff to teach them
how to recognize, manage, and sometimes prevent behavioral problems, stress reduction
for caregivers, and, for patients living at home, enrollment in adult day programs offering
structured activities and social stimulation. The evidence evaluating non-pharmacological
interventions varies considerably in quality and amount, but broadly supports an
individualized approach that includes one or more such interventions.
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
A management plan that assesses the severity and intrusiveness of problematic behaviors
can assist clinicians in determining what pharmacologic or non-pharmacologic
interventions might be appropriate.66 Mild forms of neuropsychiatric symptoms may be
alleviated with psychosocial or environmental interventions. For aggressiveness,
presentations of psychosis, or agitation, pharmacologic approaches may be more
appropriate.67 If pharmacologic approaches are necessary, they should be administered at
the lowest effective dose and their use should be reevaluated and their benefit documented
on an ongoing basis.21
A 2007 analysis of medical records and caregiver surveys for 378 patients with dementia
found that only 33.7% of patients were recommended two or more nonpharmacologic
approaches for behavior problems in the previous 12 months.6 Another study surveying
clinicians practicing in VA medical centers found that clinicians reported prescribing
medications for behavior problems for a median of 22% of their patients.7
 Equitable
 Effective
This measure has no exceptions.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
 Quality improvement
 Accountability
 Process
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
25
Level of
Measurement
Care setting
Data source
 Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
Additional Information
Measure #5 is paired with Measure #4 (Neuropsychiatric Symptom Assessment). The pairing of these measures
is not intended to suggest the use of any particular scoring methodology (ie, a composite score), nor does it
imply either equality of or difference in the relative “weights” of the two measures. A performance score for
each measure should be reported individually to provide actionable information upon which to focus quality
improvement efforts.
The NQF provides definitions of paired and composite measures65:

Paired measures are individual measures that should be measured concurrently in the same population;
however, the results are not combined into a single score (eg, measuring mortality and readmission and
displaying them together—but not calculating a joint score)

A composite measure is a combination of two or more individual measures in a single measure that results
in a single score.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
26
Measure #6: Screening for Depressive Symptoms
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia who were screened for depressive
symptoms within a 12 month period
Measure Components
Numerator
Statement
Patients who were screened for depressive symptoms* within a 12 month period
*Depressive symptoms in a patient with dementia can include: anxiety, sadness, lack of
reactivity to pleasant events, irritability, agitation, retardation, multiple physical
complaints, acute loss of interest, appetite loss, lack of energy, diurnal variation of mood,
difficulty falling asleep, multiple awakenings, during sleep, early morning awakenings,
suicide, self-depreciation, pessimism, mood congruent delusions.68 Since patients may be
unable to describe their symptoms, caregiver report of depressive symptoms should be
reviewed and included in the screen for depressive symptoms.
In addition to clinical qualitative approaches, dementia patients can be screened for
depressive symptoms using one of a number of valid, reliable instruments available from
the medical literature. Examples include, but are not limited to:
Cornell Scale for Depression in Dementia
Geriatric Depression Scale [Note: a short form is also available.]
PHQ-9
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
None
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
Depression is a common, treatable comorbidity in patients with dementia and should be
screened for (Guideline). (AAN, 2001)18
Ongoing assessment includes periodic monitoring of the development and evolution of
cognitive and noncognitive psychiatric symptoms and their response to intervention
(Category I)…Among the neuropsychiatric symptoms that require ongoing assessment are
depression (including major depression and other depressive syndromes), suicidal
ideation or behavior, hallucinations, delusions, agitation, aggressive behavior,
disinhibition, sexually inappropriate behavior, anxiety, apathy, and disturbances of
appetite and sleep. (APA, 2007)21
Conduct and document an assessment and monitor changes in behavioral symptoms,
psychotic symptoms, or depression…It is important for health care professionals
to be sensitive to symptoms of affective disorders associated with Alzheimer’s Disease
and to facilitate early intervention…Since administering assessment tests for depression
to Alzheimer’s Disease patients is often challenging and patients may be unable to
describe their symptoms to the [primary care practitioner], gathering data from family
members becomes especially important…The Cornell Scale for Depression in Dementia is
a useful tool for providers because it captures both patient and caregiver input.
(California Workgroup on Guidelines for Alzheimer’s Disease Management, 2008)24
In patients with serious illness at the end of life, clinicians should regularly assess
patients for pain, dyspnea, and depression. (Grade: strong recommendation, moderate
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
27
quality of evidence.) (ACP, 2008)69
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Depression is one of the most common co-occurring psychiatric conditions in dementia
patients, affecting over 50% of patients with Alzheimer’s disease.42 Depression can be
reliably detected and quantified, and can be differentiated from the other neuropsychiatric
symptoms of dementia.70 The impact of depression is significant with even mild levels of
depression in dementia patients associated with higher rates of disability, impaired quality
of life, and greater mortality.21 In particular, Alzheimer’s disease patients with depression
have demonstrated “significantly more severe apathy, delusions, anxiety, pathological
affective crying, irritability, deficits in activities of daily living, impairments in social
functioning, and parkinsonism than Alzheimer’s disease patients without depression.”42
Furthermore, with increasing severity of depression, the severity of psychopathological and
neurological impairments in dementia patients increases.42 Identifying depression in
patients with dementia is therefore essential for early intervention and proper
management.
A recent study examining the variability between clinical subspecialties in the outpatient
evaluation and treatment of dementia reviewed medical records of 1,401 patients with
dementia. They found that 63.4% of patients were given formal instruments for depression
screening.71 Similar results were reported in a 2007 analysis of medical records and
caregiver surveys for 378 patients with dementia with 73% of patients receiving an
assessment of behavioral problems or depression in the previous 12 months.6
 Equitable
 Effective
This measure has no exceptions.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (inpatient or outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
28
Measure #7: Counseling Regarding Safety Concerns
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled
or referred for counseling regarding safety concerns within in a 12 month period
Measure Components
Numerator
Statement
Patients or their caregiver(s) who were counseled* or referred for counseling regarding
safety concerns within a 12 month period
*Counseling should include a discussion with the patient and their caregiver(s) regarding
one or more of the following common safety concerns and potential risks to the patient.
When appropriate, it should also include a recommendation or referral for a home safety
evaluation.
Safety concerns include, but are not limited to:

Fall risk

Gait/balance

Medication management

Financial management

Home safety risks that could arise from cooking or smoking

Physical aggression posing threat to self, family caregiver, or others

Wandering

Access to firearms or other weapons

Access to potentially dangerous materials

Being left alone in home or locked in room

Inability to respond rapidly to crisis/household emergencies

Driving

Operation of hazardous equipment

Suicidality

Abuse or neglect
Note: for nursing home patients, different safety concerns might apply.
A number of organizations have developed educational materials that are recommended
to aid implementation of the measure. These materials/tools include:

Alzheimer’s Association Safety Topics. Available at:
http://www.alz.org/alzheimers_disease_publications_safety.asp

Alzheimer’s Disease Education and Referral Center’s Home Safety for the Alzheimer’s
Patient. Available at: http://www.nia.nih.gov/Alzheimers/
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
Documentation of medical reason(s) for not counseling regarding safety concerns (eg,
patient at end of life, other medical reason)
Supporting
Guideline &
Other
References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
Recommended assessments include evaluation of suicidality, dangerousness to self and
others, and the potential for aggression, as well as evaluation of living conditions, safety
of the environment, adequacy of supervision, and evidence of neglect or abuse (Category
I). [I]mportant safety issues in the management of patients with dementia include
interventions to decrease the hazards of wandering and recommendations concerning
activities such as cooking, driving, hunting, and the operation of hazardous equipment.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
29
Caregivers should be referred to available books [and other materials] that provide advice
and guidance about maximizing the safety of the environment for patients with
dementia…As patients become more impaired, they are likely to require more supervision
to remain safe, and safety issues should be addressed as part of every evaluation.
Families should be advised about the possibility of accidents due to forgetfulness (e.g.,
fires while cooking), of difficulties coping with household emergencies, and of the
possibility of wandering. Family members should also be advised to determine whether
the patient is handling finances appropriately and to consider taking over the paying of
bills and other responsibilities. At this stage of the disease [ie, moderately impaired
patients], nearly all patients should not drive. (APA, 2007)21
Safety issues such as driving, fall risk, medication management, environmental hazards,
wandering, and access to firearms need to be discussed periodically with the patient
and caregiver. Safety concerns typically focus on three risks in particular: falling,
wandering, and driving. (California Workgroup on Guidelines for Alzheimer’s Disease
Management, 2008)24
For mild to moderate Alzheimer's disease
Assess for safety risks (e.g., driving, financial management, medication management,
home safety risks that could arise from cooking or smoking, potentially dangerous
behaviours such as wandering) (Canadian Consensus Conference on Diagnosis and
Treatment of Dementia, 2008)36
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
The vast majority (87%) of individuals with Alzheimer’s disease are cared for at home by
family members.1 “As the disease progresses however, physical features of the home
environment may present as a safety hazard or barrier to performing activities of daily
living, particularly at the moderate stage of the disease process.”72 Safety concerns should
be addressed with patients and their caregivers throughout the course of the disease.
For only 26% of patients with dementia, did the physician discuss or refer for discussion
about patient safety, provide education on how to deal with conflicts at home, and inform
them about community resources for dementia in a study analyzing the quality of health
care provided to a vulnerable community-dwelling older patients.5 A 2007 analysis of
medical records and caregiver surveys for 378 patients with dementia found that only
20.6% of patients received recommended safety care processes.6
 Patient-centered
 Safe
 Equitable
This measure has no exceptions.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
30
Measure #8: Counseling regarding Risks of Driving
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled
regarding the risks of driving and the alternatives to driving at least once within a 12 month period
Measure Components
Numerator
Statement
Patients or their caregiver(s) who were counseled regarding the risks of driving and the
alternatives to driving at least once within a 12 month period
One resource that includes patient and caregiver educational materials that can be used to
aid implementation of the measure is the Physician's Guide to Assessing and Counseling
Older Drivers, developed by the American Medical Association in cooperation with the
National Highway Traffic Safety Administration,. This document is available at:
http://www.ama-assn.org/ama/pub/physician-resources/public-health/promotinghealthy-lifestyles/geriatric-health/older-driver-safety/assessing-counseling-olderdrivers.shtml.
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
Documentation of medical reason(s) for not counseling regarding the risks of driving (eg,
patient is no longer driving, other medical reason)
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
A diagnosis of Alzheimer’s disease is not, on its own, a sufficient reason to withdraw
driving privileges. The determining factor in withdrawing driving privileges should be an
individual’s driving ability. (Alzheimer’s Association, 2001)73
All patients and families should be informed that even mild dementia increases the risk of
vehicular accidents (Category I). Mildly impaired patients should be advised to limit their
driving to safer situations or to stop driving (Category I), and moderately impaired
patients should be instructed not to drive (Category I). Advice about driving cessation
should also be communicated to family members, as the implementation of the
recommendation often falls on them (Category I). Relevant state laws regarding
notification should be followed (Category I). (APA, 2007)21
For patients with dementia, consider the following characteristics useful for identifying
patients at increased risk for unsafe driving: the Clinical Dementia Rating scale (Level A), a
caregiver’s rating of a patient’s driving ability as marginal or unsafe (Level B), a history of
crashes or traffic citations (Level C), reduced driving mileage or self-reported situational
avoidance (Level C), Mini-Mental State Examination scores of 24 or less (Level C), and
aggressive or impulsive personality characteristics (Level C). Consider the following
characteristics not useful for identifying patients at increased risk for unsafe driving: a
patient’s self-rating of safe driving ability (Level A) and lack of situational avoidance (Level
C). There is insufficient evidence to support or refute the benefit of neuropsychological
testing, after controlling for the presence and severity of dementia, or interventional
strategies for drivers with dementia (Level U). Clinicians may present patients and their
caregivers with the data showing that, as a group, patients with mild dementia (CDR of 1)
are at a substantially higher risk for unsafe driving and thus should strongly consider
discontinuing driving. At the very least, patients and their caregivers should prepare for
the eventuality of driving cessation as dementia severity increases. (AAN, 2010)20
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
31
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
Motor vehicle-related injuries are a leading cause of injury deaths in adults over 65.74 Per
mile driven, drivers age 75 and older are involved in significantly more motor vehicle
crashes than middle-aged drivers.74 Dementia has a negative impact on driving skills which
deteriorate with increasing dementia severity.20 Compared with cognitively intact older
adults drivers, studies suggest that drivers with dementia have at least a 2-fold greater risk
of crashes.75 “Physicians can influence their patients’ decisions to modify or stop driving.
They can also help their patients maintain safe driving skills.”74 Clinicians should address
the risks of driving in patients with dementia for the safety of the patient and everyone on
the road.
A 2007 analysis of medical records and caregiver surveys for 378 patients with dementia
found that only 15.6% of patients had their dementia diagnosis ever reported to the county
health department for referral to the Department of Motor Vehicles (as is required in some
states) or nondriving status documented.6
 Patient-centered
 Safe
 Equitable
A medical reason exception has been included so that clinicians can exclude patients for
whom counseling regarding the risks of driving may not be appropriate (eg, patients who
are no longer driving).
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
32
Measure #9: Palliative Care Counseling and Advance Care
Planning
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who received 1)
comprehensive counseling regarding ongoing palliation and symptom management and end of life decisions
AND 2) have an advance care plan or surrogate decisions maker in the medical record or documentation in the
medical record that the patient did not wish or was not able to name a surrogate decision maker or provide an
advance care plan within two years of initial diagnosis or assumption of care
Measure Components
Numerator
Statement
Patients or their caregiver(s) who received 1) comprehensive counseling regarding ongoing
palliation and symptom management and end of life decisions* AND 2) have an advance
care plan or surrogate decisions maker in the medical record or documentation in the
medical record that the patient did not wish or was not able to name a surrogate decision
maker or provide an advance care plan** within two years of initial diagnosis or
assumption of care
*Comprehensive counseling regarding end of life decisions includes a discussion of the
risks and benefits of the following medical interventions to address the major clinical
issues associated with advanced dementia:

Hospitalization

Treatment for infections

Surgery

Artificial nutrition and hydration

Cardiopulmonary resuscitation

Mechanical ventilation

Comfort care

Timing of a natural death

Hospice referral
**Definition: Documentation in the medical record that an advance care plan was
discussed but patient did not wish or was not able to name a surrogate decision maker or
provide an advance care plan. This documentation in the medical record could also
include as appropriate that the patient's cultural and/or spiritual beliefs preclude a
discussion of advance care planning as it would be viewed as harmful to the patient's
beliefs and thus harmful to the physician-patient relationship.
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
None
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
At this stage [ie, severely and profoundly impaired patients]…the treatment team should
help the family prepare for the patient’s death. Ideally, discussions about feeding tube
placement, treatment of infection, cardiopulmonary resuscitation, and intubation will have
taken place when the patient could participate, but if they have not, it is important to raise
these issues with the family before a decision about one of these options is urgently
required. (APA, 2007)21
Advance directives and designation of healthcare surrogates should be put in place early,
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
33
while the patient can still have input. The PCP should also discuss values, preferences, and
goals related to death and dying with patients in early stages of Alzheimer’s Disease,
including do not-resuscitate orders, artificial nutrition plans, and healthcare proxies.
Expert opinion and Workgroup consensus suggest that PCPs should initiate conversations
with patients and their families about late-stage care and appointing a proxy. Proxies
should have extensive conversations with the patient about his or her wishes with respect
to a variety of circumstances and situations. (California Workgroup on Guidelines for
Alzheimer’s Disease Management, 2008)24
A crucial component of [care for nursing home residents] is providing information about
the benefits and burdens of [medical] interventions to the resident’s surrogate decision
maker, supporting development of a care plan that takes into consideration previous
wishes of the resident, if any, and his or her best interest as interpreted by the decision
maker. The care plan should consider the goals of care and priority order of the three
possible goals – survival, maintenance of function, and comfort. (Volicer L. for Alzheimer’s
Association, 2005)76
The National Hospice and Palliative Care Organization provides the Caring Connection
web site (www.caringinfo.org). This web site provides resources and information on endof-life care, including a national repository of state by state advance directives.
[Advance directives are d]esigned to respect patient's autonomy and determine his/her
wishes about future life-sustaining medical treatment if unable to indicate wishes… Key
interventions, treatment decisions to include in advance directives [are]: resuscitation
procedures, mechanical respiration, chemotherapy, radiation therapy, dialysis, simple
diagnostic tests, pain control, blood products, transfusions, intentional deep sedation.
(AGS, 2010)77
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Unlike other diseases that cause death, dementia follows a “gradual downhill course
punctuated by declines caused by acute illness that often are accompanied by delirium and
decrements in mental and functional status.”78 As a result, there are a number of end of
life considerations unique to dementia patients.79 An analysis of the clinical course of
advanced dementia found that a number of distressing symptoms and burdensome
interventions are pervasive at this stage of the disease. Dyspnea, pain, pressure ulcers and
aspiration were prevalent and were more likely to occur as the end of life approached.
Among nursing home residents who died, 40.7% underwent any one of several burdensome
interventions (ie, received parenteral therapy, were hospitalized, were taken to the
emergency room, underwent tube feeding) prior to death.80 “Aggressive medical treatment
for [nursing home] residents with advanced dementia is often inappropriate for medical
reasons, has a low rate of success, and can have negative outcomes that hasten functional
decline and death.”76 A thorough, often ongoing, discussion with patients and caregivers of
the common clinical complications of advanced dementia and corresponding medical
interventions is critical to eliciting the patient’s preferences and can help ease the decision
making burden on caregivers during more critical times.
Despite its critical importance for dementia patients, research indicates that physician
involvement in advance care counseling and planning is poor. Survey data has indicated
that while a majority of physicians reported counseling their patients with mild to
moderate Alzheimer’s disease regarding advance planning issues, only 47% discussed end
of life care.81 Among health care proxies of nursing home residents with advanced
dementia, only 32.5% stated that a physician had counseled them about clinical
complications to expect in advanced dementia and an even smaller proportion (18%) stated
that they had received prognostic information from a physician.80
 Patient-centered
 Safe
 Effective
 Equitable
This measure has no exceptions.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
34
Harmonization
with Existing
Measures
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner






Ambulatory care
Residential (ie, nursing facility, domiciliary, home care)
Electronic health record (EHR) data
Administrative Data/Claims (outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
35
Measure #10: Caregiver Education and Support
Dementia
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with
education on dementia disease management and health behavior changes AND referred to additional resources
for support within a 12 month period
Measure Components
Numerator
Statement
Patients whose caregiver(s) were provided with education* on dementia disease
management and health behavior changes AND referred to additional resources for
support within a 12 month period
*Education should also include advising the caregiver that he or she is at “increased risk of
serious illness (including circulatory and heart conditions and respiratory disease
and hypertension), increased physician visits and use of prescription medications,
emotional strain, anxiety, and depression.”24
There are a number of assessment tools available for the caregiver. These should be
considered as an integral component of comprehensive caregiver education and support.
The American Medical Association has developed a Caregiver Health Self-assessment
Questionnaire to help caregivers analyze their own health-related behavior and health
risks and, with their physician's help, make decisions that will benefit both the caregiver
and the patient. This questionnaire is available at: http://www.amaassn.org/ama/pub/physician-resources/public-health/promoting-healthylifestyles/geriatric-health/caregiver-health/caregiver-self-assessment.shtml
Denominator
Statement
All patients, regardless of age, with a diagnosis of dementia
Denominator
Exceptions
Documentation of medical reason(s) for not providing the caregiver with education on
disease management and health behavior changes or referring to additional sources for
support (eg, patient does not have a caregiver, other medical reason)
Supporting
Guideline &
Other References
The following evidence statements are quoted verbatim from the referenced clinical
guidelines:
Important aspects of psychiatric management include educating patients and families
about the illness, its treatment, and sources of additional care and support (e.g.,
support groups, respite care, nursing homes, and other long-term-care facilities) and
advising patients and their families of the need for financial and legal planning due to
the patient’s eventual incapacity (e.g., power of attorney for medical and financial
decisions, an up-to-date will, and the cost of long-term care) (Category I)… The family
should be educated regarding basic principles of care, including 1) recognizing declines in
capacity and adjusting expectations appropriately, 2) bringing sudden declines in function
and the emergence of new symptoms to professional attention, 3) keeping requests and
demands relatively simple, 4) deferring requests if the patient becomes overly upset or
angered, 5) avoiding overly complex tasks that may lead to frustration, 6) not confronting
patients about their deficits, 7) remaining calm, firm, and supportive and providing
redirection if the patient becomes upset, 8) being consistent and avoiding unnecessary
change, and 9) providing frequent reminders, explanations, and orientation cues… In
addition to providing families with information on support groups, there are a number of
benefits of referral to the local chapter or national office of the Alzheimer’s Association
(1-800-272-3900; http://www.alz.org), the Alzheimer’s Disease Education and Referral
Center (ADEAR) (1-800-438-4380; http://www.nia.nih.gov/Alzheimers/), and other support
organizations. (APA, 2007)21
Studies have shown that education and support for caregivers increases the chances of
adherence to treatment recommendations for patients. The PCP should provide
information and education about the current stage of the disease process and talk with
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
36
the patient and family to establish treatment goals. Based on the agreed-upon goals, a
discussion regarding the expected effects (positive and negative) of interventions on
cognition, mood, and behavior will ensure that the prescribed treatment strategy is
appropriate to family values and culture. (California Workgroup on Guidelines for
Alzheimer’s Disease Management, 2008)24
Seamless resource referral and access to critical services for both patients and caregivers
are considered essential. The PCP should encourage the caregiver to participate in
educational programs, support groups, respite services, and adult day service programs.
The local Alzheimer’s Association chapter or other local agency support groups and
community resources such as the Caregiver Resources Centers should be recommended.
(California Workgroup on Guidelines for Alzheimer’s Disease Management, 2008)24
Measure Importance
Relationship to
desired
outcome
Opportunity
for
Improvement
IOM Domains
of Health Care
Quality
Addressed
Exception
Justification
Harmonization
with Existing
Measures
The vast majority (87%) of individuals with Alzheimer’s disease are cared for at home by
family members.1 Chodosh et al. found that greater caregiver knowledge of dementia
management was associated with higher care quality.6 Other studies have indicated that
intensive caregiver support in the form of individual and family counseling and on-going
telephone counseling results in improved patient health outcomes.82,83 Providing education
to caregivers and referring them to additional sources for support is a critically important
piece of comprehensive care for patients with dementia.
A 2007 analysis of medical records and caregiver surveys for 378 patients with dementia
found that only 51.6% of patients received recommended education or support services. In
particular, caregiver support activities were recommended to only 24.6% of caregivers while
referral to community agencies, including the Alzheimer’s Association or Caregiver’s
Resource Center, was more frequent (78.6%).6 Another study surveying clinicians practicing
in VA medical centers found that clinicians reported provision of patient and family
education and support varied by activity. 74% of clinicians reported routinely telling the
family about the disease course while 60% reported explaining the care needs to the family
and even less (33%) reported referring the caregiver to the community.7
 Equitable
 Effective
 Patient-centered
Given the measure’s focus on patient’s caregivers, a medical reason exception has been
included so that clinicians can exclude patients without a caregiver and to whom the
measure does not apply.
Harmonization with existing measures was not applicable to this measure.
Measure Designation
Measure purpose
Type of measure
Level of
Measurement
Care setting
Data source




Quality improvement
Accountability
Process
Individual practitioner





Ambulatory care
Electronic health record (EHR) data
Administrative Data/Claims (inpatient or outpatient claims)
Administrative Data/Claims Expanded (multiple-source)
Paper medical record
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
37
Evidence Classification and Rating Schemes
Dementia
APA practice guideline for the treatment of patients With Alzheimer’s Disease and Other Dementias
Each recommendation is identified as falling into one of three categories of endorsement, indicated by a
bracketed Roman numeral following the statement. The three categories represent varying levels of clinical
confidence:
[Category I]:
Recommended with substantial clinical confidence.
[Category II]:
Recommended with moderate clinical confidence.
[Category III]:
May be recommended on the basis of individual circumstances.
Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia
Grades indicating the strength of recommendations
A) There is good evidence to support this manoeuvre.
B) There is fair evidence to support this manoeuvre.
C) There is insufficient evidence to recommend for or against this manoeuvre but recommendations may be
made on other grounds.
D) There is a fair evidence to recommend against this procedure.
E) There is good evidence to recommend against this procedure.
Levels of evidence
1. Evidence obtained from at least 1 properly randomized controlled trial.
2.1. Evidence obtained from well-designed controlled trials without randomization, or
2.2. Evidence obtained from well-designed cohort or case–control analytic studies preferably from more than 1
centre or research group, or
2.3. Evidence obtained from comparisons between times or places with or without the intervention. Dramatic
results in uncontrolled experiments are included in this category.
3. Opinions of respected authorities based on clinical experience, descriptive studies or reports of expert
committees.
The American College of Physicians' Guideline: Evidence-based interventions to improve the palliative care of
pain, dyspnea, and depression at the end of life
Strength of Recommendation
Benefits Clearly Outweigh Risks and
Quality of Evidence
Benefits Finely Balanced with Risks
Burden OR Risks and Burden Clearly
and Burden
Outweigh Benefits
High
Strong
Weak
Moderate
Strong
Weak
Low
Strong
Weak
Insufficient evidence to
I - recommendation
determine benefits or risks
AAN practice parameter for diagnosis of dementia
Class
Description
I
Evidence provided by a well designed prospective study in a broad spectrum of
persons with the suspected condition, using a “gold standard” for case
definition, in which test is applied in a blinded evaluation, and enabling the
assessment of appropriate tests of diagnostic accuracy.
II
Evidence provided by a well designed prospective study of a narrow spectrum
of persons with the suspected condition, or a well designed retrospective
study of a broad spectrum of persons with an established condition (by “gold
standard”) compared with a broad spectrum of controls, in which test is
applied in blinded evaluation, and enabling the assessment of appropriate
tests of diagnostic accuracy.
III
Evidence provided by a retrospective study in which either persons with the
established condition or controls are of a narrow spectrum, and in which test
is applied in a blinded evaluation.
IV
Any design in which test is not applied in blinded evaluation OR evidence
provided by expert opinion alone or in descriptive case series (without
controls).
Definitions for practice
recommendations based on
classification of evidence
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
38
Recommendation
Standard
Guideline
Practice Option
Practice Advisory
Description
Principle for patient management that reflects a high degree of clinical
certainty (usually this requires Class I evidence that directly addresses the
clinical question, or overwhelming Class II evidence when circumstances
preclude randomized clinical trials).
Recommendation for patient management that reflects moderate clinical
certainty (usually this requires Class II evidence or a strong consensus of
Class III evidence).
Strategy for patient management for which the clinical utility is uncertain
(inconclusive or conflicting evidence or opinion).
Practice recommendation for emerging and/or newly approved therapies or
technologies based on evidence from at least one Class I study. The evidence
may demonstrate only a modest statistical effect or limited (partial) clinical
response, or significant cost-benefit questions may exist. Substantial (or
potential) disagreement among practitioners or between payers and
practitioners may exist.
AAN practice parameter for evaluation and management of driving risk in dementia
Classification of recommendations

A = Established as effective, ineffective or harmful (or established as useful/predictive or not
useful/predictive) for the given condition in the specified population. (Level A rating requires at least two
consistent Class I studies.)

B = Probably effective, ineffective or harmful (or probably useful/predictive or not useful/predictive) for the
given condition in the specified population. (Level B rating requires at least one Class I study or two
consistent Class II studies.)

C = Possibly effective, ineffective or harmful (or possibly useful/predictive or not useful/predictive) for the
given condition in the specified population. (Level C rating requires at least one Class II study or two
consistent Class III studies.)

U = Data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven.
Classification of evidence for the rating of a diagnostic article

Class I: A cohort study with prospective data collection of a broad spectrum of persons with the suspected
condition, using an acceptable reference standard for case definition. The diagnostic test is objective or
performed and interpreted without knowledge of the patient’s clinical status. Study results allow calculation
of measures of diagnostic accuracy.

Class II: A case control study of a broad spectrum of persons with the condition established by an
acceptable reference standard compared to a broad spectrum of controls or a cohort study where a broad
spectrum of persons with the suspected condition where the data was collected retrospectively. The
diagnostic test is objective or performed and interpreted without knowledge of disease status. Study results
allow calculation of measures of diagnostic accuracy.

Class III: A case control study or cohort study where either persons with the condition or controls are of a
narrow spectrum. The condition is established by an acceptable reference standard. The reference standard
and diagnostic test are objective or performed and interpreted by different observers. Study results allow
calculation of measures of diagnostic accuracy.

Class IV: Studies not meeting Class I, II or III criteria including consensus, expert opinion or a case report.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
39
Summary of Non-Material Interest Disclosures
Dementia
None of the members of the Dementia Work Group had any disqualifying material interests under the PCPI
Conflict of Interest Policy. The following is a summary of non-disqualifying interests disclosed on Work Group
members' Material Interest Disclosure Statements. Completed Material Interest Disclosure Statements are
available upon request.
Work Group Member
Disclosures
_Jerry C. Johnson_____ (Co-Chair)
_Germaine Odenheimer (Co-Chair)
_Francois Boller______
_Soo Borson_________
_Charles A. Cefalu____
_Mirean Coleman___
_Patricia C. Davis_____
_Mary Ann Forciea____
_Elizabeth M. Galik____
None
None
None
None
None
None
None
None
Payment for Consulting Services: Novartis – Development
of nurse practitioner education material on Dementia
_Laura N. Gitlin______
_Helen H. Kyomen____
Katie Maslow
Haydee Muse
Bruce E. Robinson
Robert Paul Roca
Amy E. Sanders
Jason E. Schillerstrom
Joseph W. Shega
Eric G. Tangalos
None
None
None
None
None
None
None
None
None
Stock Ownership: Johnson & Johnson (family member)
Research or Other Grant Support: Baxter
Payment for Consulting Services: Novartis
Other Payments: Lilly – Participation on a data safety
monitoring board
Joan M. Teno
Brian K. Unwin
None
None
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
40
References
Alzheimer’s Association. 2009 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association ; 2009.
http://www.alz.org/national/documents/report_alzfactsfigures2009.pdf. Accessed February 24, 2010.
2
Alzheimer’s Association. 2010 Alzheimer’s Disease Facts and Figures. Alzheimer’s Association; 2010.
http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf. Accessed August 19, 2010.
3
Xu JQ, Kochanek KD, Murphy SL, Tejada-Vera B. Deaths: final data for 2007. Hyattsville, MD: US Department of
Health and Human Services, CDC, National Center for Health Statistics; 2010. National Vital Statistics Report,
vol. 58, no. 19. Available at http: //www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_19.pdf. Accessed August 17,
2011.
4
Alzheimer’s Disease International. World Alzheimer Report 2010: The global economic impact of dementia.
http://www.alz.org/documents/national/World_Alzheimer_Report_2010.pdf. Accessed September 28, 2010.
5
Wenger N, Solomon D, Roth C et al. The quality of medical care provided to vulnerable community-dwelling
older patients. Ann Intern Med. 2003;139:740–747.
6
Chodosh J, Mittman BS, Connor KI. Caring for patients with dementia: How good is the quality of care?
Results from three health systems. J Am Geriatr Soc. 2007 Aug;55(8):1260-8.
7
Rosen CS, Chow HC, Greenbaum MA, et al. How well are clinicians following dementia practice guidelines?
Alzheimer Dis Assoc Disord. 2002;16(1): 15-23.
8
Cooper C, Tandy AR, Balamurali TB, Livingston G. A systematic review and meta-analysis of ethnic differences
in use of dementia treatment, care, and research. Am J Geriatr Psychiatry. 2010 Mar;18(3):193-203.
9
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC:
National Academy Press; 2001.
10
Feldman HH, Jacova C, Robillard A, et al. Diagnosis and treatment of dementia: 2. Diagnosis. CMAJ
2008;178:825-36.[
11
Clark PC, Kutner NG, Goldstein FC, et al. Impediments to timely diagnosis of Alzheimer’s disease in African
Americans. J Am Geriatr Soc. 2005 Nov;53(11):2012-7. Cited by: Zuckerman IH, Ryder PT, Simoni-Wastila L, et
al. Racial and ethnic disparities in the treatment of dementia among Medicare beneficiaries. J Gerontol B Psychol
Sci Soc Sci. 2008 Sep;63(5):S328-33.
12
Leo RJ, Narayan DA, Sherry C. Geropsychiatric consultation for African American and Caucasian patients. Gen
Hosp Psychiatry. 1997 May;19(3):216-22. Cited by: Zuckerman IH, Ryder PT, Simoni-Wastila L, et al. Racial and
ethnic disparities in the treatment of dementia among Medicare beneficiaries. J Gerontol B Psychol Sci Soc Sci.
2008 Sep;63(5):S328-33.
13
Zuckerman IH, Ryder PT, Simoni-Wastila L, et al. Racial and ethnic disparities in the treatment of dementia
among Medicare beneficiaries. J Gerontol B Psychol Sci Soc Sci. 2008 Sep;63(5):S328-33.
14
Stevens A, Owen J, Roth D, Clay O, Bartolucci A, Haley W. Predictors of time to nursing home placement in
White and African American individuals with dementia. J Aging Health. 2004 Jun;16(3):375-97. Cited by:
Zuckerman IH, Ryder PT, Simoni-Wastila L, et al. Racial and ethnic disparities in the treatment of dementia
among Medicare beneficiaries. J Gerontol B Psychol Sci Soc Sci. 2008 Sep;63(5):S328-33.
15
Yaffe K, Fox P, Newcomer R, et al. Patient and caregiver characteristics and nursing home placement in
patients with dementia. JAMA. 2002 Apr 24;287(16):2090-7.
16
National Quality Forum Issue Brief (No.10). Closing the Disparities Gap in Healthcare Quality with Performance
Measurement and Public Reporting. Washington, DC: NQF, August 2008.
17
Agency for Healthcare Research and Quality. Race, Ethnicity, and Language Data: Standardization for Health
Care Quality Improvement. March 2010. AHRQ Publication No. 10-0058-EF.
http://www.ahrq.gov/research/iomracereport. Accessed May 25, 2010.
18
Knopman ST, DeKosky JL, Cummings H, et al. Practice parameter: Diagnosis of dementia (an evidence-based
review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology.
2001;56;1143-1153.
19
Doody RS, Stevens JC, Beck C. Practice Parameter: Management of Dementia (An evidence-based review):
Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56
:1154-1166.
20
Iverson DJ, Gronseth GS, Reger MA, Classen S, Dubinsky RM, Rizzo M. Practice Parameter update: Evaluation
and management of driving risk in dementia: Report of the Quality Standards Subcommittee of the American
Academy of Neurology. Neurology. 2010;74:1316-1324.
21
American Psychiatric Association (APA). Practice guideline for the treatment of patients with Alzheimer's
disease and other dementias. Arlington (VA): American Psychiatric Association (APA); 2007 Oct.
22
American Medical Directors Association. Dementia Clinical Practice Guideline. Columbia, MD: AMDA 2009.
23
Chertkow H. Diagnosis and treatment of dementia: introduction. Introducing a series based on the Third
Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. CMAJ. 2008;178:316-21.
24
California Workgroup on Guidelines for Alzheimer’s Disease Management. Guidelines for Alzheimer’s disease
management. Los Angeles, CA: Alzheimer’s Disease and Related Disorders Association, Inc., Los Angeles
Chapter. 2008.
1
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
41
Physician Consortium for Performance Improvement (PCPI) Web site. PCPI position statement: the evidence
base required for measure development. http://www.ama-assn.org/ama/pub/physician-resources/clinicalpractice-improvement/clinical-quality/physician-consortium-performance-improvement/position-papers.shtml.
Accessed June 25, 2010.
26
Herrmann N, Gauthier S. Diagnosis and treatment of dementia: 6. Management of severe Alzheimer disease.
CMAJ. December 2, 2008; 179(12): 1279 - 1287.
27
National Library of Medicine. Medical Subject Headings Caregiver Descriptor Data. Available at:
http://www.nlm.nih.gov/mesh/meshhome.html. Accessed August 17, 2011.
28
The Cornell Scale for Depression in Dementia Administration & Scoring. Available at: http://www.dementiaassessment.com.au/depression/Cornel_Scale_Guidelines.pdf. Accessed August 17, 2011.
29
Callahan CM, Hendrie HC, Tierney WM. Documentation and Evaluation of Cognitive Impairment in Elderly
Primary Care Patients. Ann Intern Med. 1995;122:422-429.
30
Boise L, Neal MB, and Kaye J. Dementia assessment in primary care: Results from a study in three managed
care systems. J Gerontol: Medical Sciences. 2004;59A(6):621-626.
31
Valcour VG, Masaki KH, Curb JD, Blanchette PL. The detection of dementia in the primary care setting. Arch
Intern Med. 2000;160:2964-2968.
32
Ganguli M, Rodriguez E, Mulsant B, et al. Detection and Management of Cognitive Impairment in Primary Care:
The Steel Valley Seniors Survey. J Am Geriatr Soc. 2004;52:1668-1675.
33
Boustani M, Callahan CM, Unverzagt FW, et al. Implementing a screening and diagnosis program for dementia
in primary care. Journal of General Internal Medicine. 2005;20:572-577.
34
Borson S, Scanlan JM, Watanabe J, Tu S-P, and Lessig M. Improving identification of cognitive impairment in
primary care. International Journal of Geriatric Psychiatry 2006;21(4):349-355.
35
Ashford JW, Borson S, O’Hara R, et al. Should older adults be screened for dementia? It is important to screen
for evidence of dementia! Alzheimers Dement. 2007 Apr;3(2):75-80.
25
36
Hogan DB, Bailey P, Black S, et al. Diagnosis and treatment of dementia: 4. Approach to
management of mild to moderate dementia. CMAJ. 2008;179:787-93.
Chow TW, MacLean CH. Quality indicators for dementia in vulnerable community-dwelling and hospitalized
elders. Ann Intern Med. 2001 Oct 16;135(8 Pt 2):668-76.
38
National Institutes of Health (NIH). NIH State-of-the-Science Conference: Preventing Alzheimer’s Disease and
Cognitive Decline. April 26–28, 2010. http://consensus.nih.gov/2010/docs/alz/alz_stmt.pdf. Accessed June 9,
2010.
39
Wilson RS, Aggarwal NT, Barnes LL, Mendes de Leon CF, Hebert LE, Evans DA. Cognitive decline in incident
Alzheimer disease in a community population. Neurology. 2010 Mar 23;74(12):951-5.
40
Lechowski L, Van Pradelles S, Le Crane M, et al; and REAL Group. Patterns of loss of basic activities of daily
living in Alzheimer patients: A cross-sectional study of the French REAL cohort. Dement Geriatr Cogn Disord.
2010;29(1):46-54.
41
Andersen CK, Wittrup-Jensen KU, Lolk A, Andersen K, Kragh-Sørensen P. Ability to perform activities of daily
living is the main factor affecting quality of life in patients with dementia. Health Qual Life Outcomes. 2004,
2:52.
42
Starkstein SE, Jorge R, Mizrahi R, Robinson RG. The Construct of Minor and Major Depression in Alzheimer’s
Disease. Am J Psychiatry. 2005;162:2086-2093.
43
Boyle PA, Malloy PF, Salloway S, Cahn-Weiner DA, Cohen R, Cummings JL. Executive dysfunction and apathy
predict functional impairment in Alzheimer disease. Am J Geriatr Psychiatry. 2003 Mar-Apr;11(2):214-21.
44
Steeman E, Abraham IL, Godderis J. Risk profiles for institutionalization in a cohort of elderly people with
dementia or depression. Arch Psychiatr Nurs. 1997;11, 295-303.
45
Bracco L, Gallato R, Grigoletto F, et al. Factors affecting course and survival in Alzheimer's disease. A 9-year
longitudinal study. Arch Neurol. 1994 Dec;51(12):1213-9.
46
Loreck DJ, Bylsma FW, Folstein MF. A New Scale for Comprehensive Assessment of Psychopathology in
Alzheimer's Disease. Am J Geriatr Psychiatry. 1994, 2:52-59.
47
Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J. The Neuropsychiatric
Inventory: comprehensive assessment of psychopathology in dementia. Neurology. 1994, 44(12):2308-14.
48
International Psychogeriatric Association. Introduction to Behavioral and Psychological Symptoms of
Dementia (Revised). http://www.ipa-online.org/ipaonlinev3/ipaprograms/bpsdarchives/bpsdrev/toc.asp.
Accessed May 20, 2010.
49
Lyketsos CG, Lopez O, Jones B, Fitzpatrick AL, Breitner J, DeKosky S. Prevalence of neuropsychiatric
symptoms in dementia and mild cognitive impairment: results from the Cardiovascular Health Study. JAMA.
2002; 288:1475-1483.
50
Ikeda M, Fukuhara R, Shigenobu K, et al. Dementia associated mental and behavioural disturbances in elderly
people in the community: findings form the first Nakayama study. J Neurol Neurosurg Psychiatry. 2004; 75:146148.
51
Liu CY, Wang PN, Lin KN, Liu HC. Behavioral and psychological symptoms in Taiwanese patients with
Alzheimer’s disease. Int Psychogeriatr. 2007; 19:605-613.
37
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
42
Zuidema SU, Derksen E, Verhey FR, Koopmans RT. Prevalence of neuropsychiatric symptoms in a large sample
of Dutch nursing home patients with dementia. Int J Geriatr Psychiatry. 2007; 22:632-638.
53
Kverno KS, Black BS, Blass DM, Geiger-Brown J, Rabins PV. Neuropsychiatric symptom patterns in hospiceeligible nursing home residents with advanced dementia. J Am Med Dir Assoc. 2008; 7:509-15.
54
Chui HC, Lyness SA, Sobel E, Schneider LS. Extrapyramidal signs and psychiatric symptoms predict faster
cognitive decline in Alzheimer's disease. Arch Neurol. 1994; 51:676–681.
55
Weiner MF, Hynan LS, Bret ME, White C,III. Early behavioral symptoms and course of Alzheimer’s disease. Acta
Psychiatr Scand. 2005; 111:367-371.
56
Leger JM, Moulias R, Robert P, et al. Agitation and aggressiveness among the elderly population living in
nursing or retirement homes in France. Int Psychogeriatr. 2002; 14:405-416.
57
Malone ML, Thompson L, Goodwin JS: Aggressive behaviors among the institutionalized elderly. J Am Geriatr
Soc. 1993; 41:853-856.
58
Kunik ME, Snow AL, Molinari VA, et al. Health care utilization in dementia patients with psychiatric
comorbidity. Gerontologist. 2003; 43:86-91.
59
Kunik ME, Cully JA, Snow L, Souchek J, Sullivan G, Ashton CM. Treatable comorbid conditions and use of VA
health care services among patients with dementia. Psychiatr Serv. 2005; 56:70-75.
60
Steele C, Rovner B, Chase GA, Folstein M. Psychiatric symptoms and nursing home placement of patients with
Alzheimer’s disease. Am J Psychiatry. 1990; 147:1049-1051.
61
Knopman DS, Berg JD, Thomas R, Grundman M, Thal LJ, Sano M, and for members of the Alzheimer’s Disease
Cooperative Study. Nursing home placement is related to dementia progression: experience from a clinical trial.
Neurology. 1999; 52:718-718.
62
Donaldson C, Tarrier N, Burns A. Determinants of carer stress in Alzheimer’s disease. Int J Geriatr Psychiatr.
1998; 13:248-256.
63
Miyamoto Y, Ito H, Otsuka T, Kurita H. Caregiver burden in mobile and non-mobile demented patients: a
comparative study. Int J Geriatr Psychiatry. 2002; 17:765-773.
64
Snyder L, Jenkins C, Joosten L. Effectiveness of support groups for people with mild to moderate Alzheimer's
disease: an evaluative survey. Am J Alzheimers Dis Other Demen. 2007; 22:14-19.
65
National Quality Forum (NQF). Composite Measure Evaluation Framework and National Voluntary Consensus
Standards for Mortality and Safety—Composite Measures: A Consensus Report. Washington, DC: NQF;2009.
66
Lawlor B. Behavioral and psychological symptoms in dementia: the role of atypical antipsychotics. J Clin
Psychiatry. 2004;65(Suppl 11):5–10.
67
Sink K, Holden K, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia. JAMA.
2005;293:596–608.
68
Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell scale for depression in dementia. Biol
Psychiatry. 1988 Feb 1;23(3):271-84.
69
Qaseem A, Snow V, Cross JT. Current Pharmacologic Treatment of Dementia: A Clinical Practice Guideline
from the American College of Physicians and the American Academy of Family Physicians. Ann Intern Med.
2008;148:370-378.
70
Lyketsos CG, Lee HB. Diagnosis and Treatment of Depression in Alzheimer's Disease A Practical Update for
the Clinician. Dement Geriatr Cogn Disord. 2004;17:55-64.
71
Kalkonde YV, Pinto-Patarroyo GP, Goldman T, et al. Differences between clinical subspecialties in the
outpatient evaluation and treatment of dementia in an academic medical center. Dement Geriatr Cogn Disord.
2010;29(1):28-36.
72
Gitlin LN, Schinfeld S, Winter L, Corcoran M, Boyce AA, Hauck W. Evaluating home environments of persons
with dementia: interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP).
Disabil Rehabil. 2002, Vol. 24, No. 1-3, Pages 59-71.
73
Alzheimer’s Association. Position statement: Driving. Adopted by the Alzheimer’s Association Board of
Directors, October 2001. Available at: http://www.alz.org/national/documents/statements_driving.pdf.
Accessed February 16, 2011.
74
American Medical Association. Physician’s Guide to Assessing and Counseling Older Drivers. 2nd edition.
2010. http://www.ama-assn.org/ama/pub/physician-resources/public-health/promoting-healthylifestyles/geriatric-health/older-driver-safety.shtml. Accessed June 15, 2010.
75
Carr DB, Ott BR. The older adult driver With cognitive impairment. “It’s a frustrating life.”
JAMA. 2010;303(16):1632-1641.
76
Volicer L. End-of-Life care for people with dementia in residential care settings. Alzheimer's Association; 2005.
http://www.nccdp.org/resources/endoflifelitreview.pdf. Accessed August 31, 2010.
77
American Geriatrics Society (AGS). Geriatrics at your fingertips: Palliative and end-of-life care. In: Reuben DB,
Herr KA, Pacala JT, et al., eds. Online edition: Geriatrics at your fingertips. 2010; 12th edition.
http://www.geriatricsatyourfingertips.org. Accessed August 31, 2010.
78
Sachs GA, Shega JW, Cox-Haley D. Barriers to excellent end-of-life care for patients with dementia. J Gen Intern
Med. 2004;19:1057e1063.
52
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
43
79
Kim KY, Yeaman PA, Keene RL. End-of-life care for persons with Alzheimer's disease. Psychiatr Serv. 2005
Feb;56(2):139-41.
80
Mitchell SL, Teno JM, Kiely D, et al. The clinical course of advanced dementia. N Engl J Med. 2009 Oct 15 361
(16):1529-38.
81
Cavalieri TA, Latif W, Cieselski J, Ciervo CAJr, Forman LJ. How physicians approach advance care planning in
patients with mild to moderate Alzheimer's disease. J Am Osteopath Assoc. 2002; 102(10):541-544.
82
Gaugler JE, Kane RL, Kane RA, Newcomer R. Unmet care needs and key outcomes in dementia. J Am Geriatr
Soc. 2005;53:2098–2105.
83
Mittelman MS, Haley WE, Clay OJ, Roth DL. Improving caregiver well-being delays nursing home placement of
patients with Alzheimer disease. Neurology. 2006;67:1592–1599.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
44
American Academy of Neurology
American Geriatrics Society
American Medical Directors Association
American Psychiatric Association
Physician Consortium for Performance Improvement® (PCPI™)
Dementia
Administrative Claims Specifications
Appendix A
PCPI Approved October 2011
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
1
T e c hnic a l S pe c i f i ca t i o n s: I nt r o d u ct i o n
There are several data sources available for collecting performance measures, generally requiring different
sets of measure specifications, due to the structure of the systems storing the data. The PCPI recognizes
that electronic health records (EHRs) are the state of the art for clinical encounters and is focusing
significant resources and expertise toward specifying and testing measures within EHRs, as they hold the
promise of providing the relevant clinical data for measures and for providing feedback to physicians and
other health care providers that is timely and actionable.
The following measure specifications include a listing of data elements required for collection of the
measures in Electronic Health Records (EHRs).
The following measure specifications are divided into four distinct categories, based on the data source
that is available to the provider or organization seeking to improve the quality of care delivered to their
patients. The PCPI recognizes that such data are usually available only to health plans (public or private)
or self-insured employers, but urges that, wherever possible, these data be shared with physician
practices. The PCPI specifies the medications that apply to each medication-related measure. National
Drug Code (NDC) lists for medication-related measures have been used in the past, however due to the
movement nationally to use RxNorm within EHRs for medications, the PCPI has begun to use RxNorm in
its quality measure specifications where EHR is the data source for medications.
Quality Re port ing and Electronic Health Records: Ov erview
Specifications to collect and report on the Dementia measures are included in this document. In light of
recent national initiatives to encourage physicians and other health care professionals to adopt and
implement Electronic Health Records (EHRs) in their practices, we highlight here some of the current PCPI
activities to promote use of these measures within EHRs.
Integration with EHRs (HQMF and eMeasure)
The Collaborative for Performance Measure Integration with EHRS--co-sponsored by the AMA, NCQA, and
the HIMSS Electronic Health Record Association (EHRA)-- works with measure developers, EHR providers,
and clinical users of EHRs to advance the use of measures within EHRs (see www.amaassn.org/go/collaborative ). Among its work, the Collaborative developed a standard Health Quality
Measure Format (available at HQMF.org) for use by EHRs and other IT providers to incorporate measure
specifications within their systems.
In Spring 2009, The National Quality Forum (NQF) funded an initiative to take the prototype HQMF XML,
now referred to as an “eMeasure,” and align it with constructs previously defined by HL7 - including the
HL7 Reference Information Model (RIM). The HQMF eMeasure was balloted and subsequently approved as
an HL7 Draft Standard for Trial Use (DSTU) in February 2010.
D e f i nit io n o f T e rm s f o r E le c t ro ni c H e a lt h R e c or d (EH R ) S p e c i f i ca t io ns
The PCPI provides definitions for terms that are in use in the Health Information Technology and Quality
Measure arenas to describe quality measure specifications.
Electronic Specification (eSpecification)
eSpecification, syn, EHR specification –a generic term used to describe a performance measure
specification that includes information to facilitate the integration and interpretation of performance
measures in electronic health records.
eMeasure
The translation of an eSpecification in computer readable format (XML) that has a specification in
accordance with the HQMF (Health Quality Measure Format), an HL7 Draft Standard for Trial Use (DSTU).
PCPI eSpecification
A type of eSpecification developed by the PCPI that includes the following:

text description

data elements (including constraints and attributes)

visual representation of the measure logic

mathematical expression to calculate the measure performance rates and exception
rates
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
2

relevant value sets
The PCPI eSpecification is “human readable” and useable by anyone wishing to understand how the data
elements for a measure are constructed and combined to calculate quality measure performance and
exception rates. It can also be used by a software developer to translate the quality measure specification
into the HQMF eMeasure format. It is the PCPI’s objective that the PCPI eSpecifications will serve as the
basis from which the HQMF eMeasure is developed. The development of the PCPI eSpecifications will
ensure that the intent of the PCPI measure is preserved when it is translated into the eMeasure format.
T e c hnic a l S pe c i f i ca t i o n s f o r D i f f e re nt D a t a S ou rc e s
The PCPI develops technical specifications for multiple data sources, including:

Electronic Health Record (EHR) Data

Electronic Administrative Data (Claims), which may include specifications for:
o Prospective Claims-based reporting (using CPT Category II codes)
o Retrospective Claims Analysis

Expanded (multiple-source) Administrative Data

Paper Medical Record Data/ Data Collection Flowsheet
We have included the recommended data source, given that not all measures are feasible for collection
and reporting from all data sources.
Electronic Health Record (EHR) Data
Specification of the performance measure by the PCPI is critical to ensure that the intent of the measure is
accurately represented prior to being integrated into an EHR. Complete PCPI eSpecifications will be
developed once the Dementia measures have been finalized by the PCPI Measure Development Workgroup.
It is anticipated that many meaningful, accurate and reliable performance measures can be computed
relying on EHR data. Our measure specifications currently include relevant coding and logic to query an
EHR for data and compute the measure provided in words and tables consistent with the National Quality
Forum’s Quality Data Model, version 2.1 (QDM). We recognize that not all EHRs in use have the
functionalities to support every data element required for these measures and, in some cases, such
functionalities are available but are not being used. Our intent, therefore, is to prioritize measures for
EHR integration in order to provide a roadmap for EHR developers and users of EHR systems
Electronic Administrative Data (Claims)
Electronic Administrative Data are typically used for reporting clinical services provided to the patient by
the physician or physician group practice to third party payers, including diagnosis (ICD-9-CM) codes and
service/procedure (CPT Category I) codes. In some cases, this information can be analyzed to provide
quality of care information. Supplemental tracking codes (CPT Category II) are developed for performance
measurement collection and reporting through a claims-based system. CPT Category II codes are optional
tracking codes that can be included on the claim for quality measure reporting, but are not required in
order to process the claim for reimbursement. The calculation of performance measure information is
determined by the claim form composition. Some claims will solely include reimbursement codes and
others will include a combination of reimbursement and supplemental tracking codes. Some performance
measures may not require the supplemental tracking codes be present on the claim form in order for the
measure to be calculated, but this is not the case for all measures. Until expanded and linked
administrative databases or electronic health record systems are more widely available and utilized,
various pay-for-performance and pay-for-reporting programs (including the Physician Quality Reporting
System [PQRS] of the Centers for Medicare and Medicaid Services [CMS]) continue to rely on this type of
claims data.
Expanded (multiple-source) Administrative Data
Expanded Administrative Data are routinely captured during the course of care delivery through either
payment or care documentation purposes and accessible through the use of large electronic databases.
Multiple organizations may gather such electronic data, including health plans (e.g., medical claims),
health systems (e.g., patient registries), and large data aggregators or warehouses. In addition to physician
claims data (as described above), these databases may aggregate data from multiple care settings (e.g.
outpatient, inpatient, emergency department and other sites of care) and may include data elements not
typically available on physician claims (e.g., pharmacy and laboratory data). While this data source
enables the use of large data sets that can be joined and analyzed through complex, programmed
algorithms, most data are currently confined to coded diagnosis and procedural claims and typically do
not include more robust clinical detail.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
3
Paper Medical Record Data/ Data Collection Flowsheet
Information from the paper medical record may be manually abstracted by prospective or retrospective
manual review of clinical encounter information. Medical record data, despite being more expensive to
acquire, can provide much richer clinical information usually not available in electronic transactional data,
alongside typical administrative claims information from the patient encounter.
D a ta E l eme nt s f o r E l e ct r o ni c H ea l t h Rec o r d (EH R) I nt eg r at io n
PCPI Specifications Staff have identified the data elements required to collect and calculate the Dementia
measures in an electronic health record. The identification of data elements is the first step in developing
specifications for implementation in an Electronic Health Record (EHR). The data elements that follow are
classified according to the National Quality Forum’s Quality Model, Version 2.1 (QDM). The QDM is a
framework that can be used to clearly define concepts used in quality measures and clinical care. It
provides a standardized method to describe data elements for electronic health record capture.
Additional background information on the Quality Data Set can be found on the NQF Website at:
http://www.qualityforum.org/Projects/h/QDS_Model/Quality_Data_Model.aspx
Once the Dementia measures have completed the public comment process and are finalized by the
Dementia Work Group, the PCPI eSpecifications (referenced above) will be developed.
PCPI Staff welcomes comments on the representation of the data elements included here for public
comment.
M e a su r e Ex ce p t io n s
For process measures, the PCPI provides three categories of reasons for which a patient may be excluded
from the denominator of an individual measure:

Medical reasons
Includes:
- not indicated (absence of organ/limb, already received/performed, other)
- contraindicated (patient allergic history, potential adverse drug interaction, other)

Patient reasons
Includes:
- patient declined
- social or religious reasons
- other patient reasons

System reasons
Includes:
- resources to perform the services not available
- insurance coverage/payor-related limitations
- other reasons attributable to health care delivery system
These measure exception categories are not available uniformly across all measures; for each measure,
there must be a clear rationale to permit an exception for a medical, patient, or system reason. Where
possible, examples have been provided in the measure exception language of instances that would
constitute an exception. Examples are intended to guide clinicians and are not all-inclusive lists of all
possible reasons why a patient could be excluded from a measure. When using CPT Category II codes to
report the measure, the exception of a patient should be reported by appending the appropriate modifier
to the CPT Category II code designated for the measure:



Medical reasons: modifier 1P
Patient reasons: modifier 2P
System reasons: modifier 3P
Although this methodology does not require the external reporting of more detailed exception data, the
PCPI recommends that clinicians document the specific reasons for exception in patients’ medical records
for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic
review and analysis of each clinician’s exceptions data to identify practice patterns and opportunities for
quality improvement. For example, it is possible for implementers to calculate the percentage of patients
that clinicians have identified as meeting the criteria for exception.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
4
Please refer to documentation for each individual measure for information on the acceptable exception
categories and the codes and modifiers to be used for reporting.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
5
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #1 – Staging of Dementia
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
6
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:
 90801, 90802
 90804, 90805,
 90810, 90811,
 90816, 90817,
 90823, 90824,
 90862
 96116, 96118,
 97003, 97004
 99201, 99202,
 99212, 99213,
 99241, 99242,
 99304, 99305,
 99307, 99308,
 99324, 99325,
 99334, 99335,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96119
99203,
99214,
99243,
99306
99309,
99326,
99336,
99204, 99205
99215
99244, 99245
99310
99327, 99328
99337
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
7
Administrative Claims Specifications
PCPI APPROVED
Dementia


Numerator
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients whose severity of dementia was classified as mild, moderate or severe at least
once within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code: 1490F: Dementia severity classified, mild
CPT Category II Code: 1491F: Dementia severity classified, moderate
CPT Category II Code: 1493F: Dementia severity classified, severe
Denominator
Exceptions
None
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 1490F OR 1491F OR 1493F to indicate dementia severity classification.
There are no performance exceptions for this measure; modifiers 1P, 2P, or 3P may not
be used.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
8
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #2 - Cognitive Assessment
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
9
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:














90801, 90802
90804, 90805,
90810, 90811,
90816, 90817,
90823, 90824,
90862
96116, 96118,
97003, 97004
99201, 99202,
99212, 99213,
99241, 99242,
99304, 99305,
99307, 99308,
99324, 99325,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96119, 96120
99203,
99214,
99243,
99306
99309,
99326,
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
10
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients for whom an assessment of cognition is performed and the results reviewed at
least once within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code: 1494F: Cognition assessed and reviewed
Denominator
Exceptions
Documentation of medical reason(s) for not assessing cognition (eg, patient at end of
life, other medical reason)
 Append modifier to CPT II code 1494F-1P
Documentation of patient reason(s) for not assessing cognition
 Append modifier to CPT II code 1494F-2P
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 1494F if assessment of cognition is performed and the results reviewed.
For patient with appropriate exception criteria report 1494F with modifier -1P or -2P.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
11
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #3 – Functional Status Assessment
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
12
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:














90801, 90802
90804, 90805,
90810, 90811,
90816, 90817,
90823, 90824,
90862
96116, 96118,
97003, 97004
99201, 99202,
99212, 99213,
99241, 99242,
99304, 99305,
99307, 99308,
99324, 99325,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96119, 96120
99203,
99214,
99243,
99306
99309,
99326,
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
13
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients for whom an assessment of functional status is performed and the results
reviewed at least once within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code: 1175F: Functional status for dementia assessed and results
reviewed
Denominator
Exceptions
Documentation of medical reason(s) for not assessing functional status (eg, patient is
severely impaired and caregiver knowledge is limited, other medical reason)
 Append modifier to CPT II code 1175F-1P
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 1175F if assessment of functional status is performed and the results reviewed.
For the patient with appropriate exception criteria, report 1175F with modifier -1P.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
14
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #4 – Neuropsychiatric Symptom Assessment
This measure is paired with Measure #5 – Management of Neuropsychiatric Symptoms
Implementers of this measure should not use Measure #4 without Measure #5.
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
15
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:
 90801, 90802
 90804, 90805,
 90810, 90811,
 90816, 90817,
 90823, 90824,
 90862
 96116, 96118,
 96150, 96151
 97003, 97004
 99201, 99202,
 99212, 99213,
 99241, 99242,
 99304, 99305,
 99307, 99308,
 99324, 99325,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96119
99203,
99214,
99243,
99306
99309,
99326,
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
16
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients for whom an assessment of neuropsychiatric symptoms is performed and results
reviewed at least once in a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 1181F: Neuropsychiatric symptoms assessed and results reviewed
Denominator
Exceptions
None
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
This measure is paired with measure #5- Management of Neuropsychiatric Symptoms.
Implementers of this measure should not use this Neuropsychiatric Symptom
Assessment without the Management of Neuropsychiatric Symptoms measure.
Report 1181F if assessment of neuropsychiatric symptoms performed and results
reviewed.
There are no performance exceptions for this measure; modifiers 1P, 2P, or 3P may not
be used.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
17
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #5 – Management of Neuropsychiatric Symptoms
This measure is paired with Measure #4 – Neuropsychiatric Symptom Assessment.
Implementers of this measure should not use Measure #5 without Measure #4.
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
18
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:














90801, 90802
90804, 90805,
90810, 90811,
90816, 90817,
90823, 90824,
90862
96150, 96151,
97003, 97004
99201, 99202,
99212, 99213,
99241, 99242,
99304, 99305,
99307, 99308,
99324, 99325,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96152, 96154, 96155
99203,
99214,
99243,
99306
99309,
99326,
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
19
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients who received or were recommended to receive an intervention for
neuropsychiatric symptoms within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 4525F: Neuropsychiatric intervention ordered
CPT Category II Code 4526F: Neuropsychiatric intervention received
Denominator
Exceptions
Additional
CPT Category
II Codes used
to report this
measure
Reporting
Instructions
None
1182F: Neuropsychiatric symptoms, one or more present
1183F: Neuropsychiatric symptoms, absent
This measure is paired with Measure #4 – Neuropsychiatric Symptom Assessment.
Implementers of this measure should not use this measure without the Neuropsychiatric
Symptom Assessment measure.
Report 1182F OR 1183F to indicate the number of neuropsychiatric symptoms. If one or
more neuropsychiatric symptoms is present (1182F), report 4525F if patient was
recommended to receive or report 4526F if patient has received an intervention for
neuropsychiatric symptoms.
There are no performance exceptions for this measure; modifiers 1P, 2P, or 3P may not
be used.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
20
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #6 – Screening for Depressive Symptoms
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
21
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:














90801, 90802
90804, 90805,
90810, 90811,
90816, 90817,
90823, 90824,
90862
96101, 96102,
96116, 96118,
96150, 96151
97003, 97004
99201, 99202,
99212, 99213,
99241, 99242,
99304, 99305,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96103
96119, 96120
99203, 99204, 99205
99214, 99215
99243, 99244, 99245
99306
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
22
Administrative Claims Specifications
PCPI APPROVED
Dementia





Numerator
99307, 99308,
99324, 99325,
99334, 99335,
99341, 99342,
99347, 99348,
99309,
99326,
99336,
99343,
99349,
99310
99327, 99328
99337
99344, 99345
99350
Patients who were screened for depressive symptoms within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 3725F: Screening for depression performed
Denominator
Exceptions
None
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 3725F if patient was screened for depressive symptoms.
There are no performance exceptions for this measure; modifiers 1P, 2P or 3P may not
be used.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
23
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #7 – Counseling Regarding Safety Concerns
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
24
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:
 90801, 90802
 90804, 90805,
 90810, 90811,
 90816, 90817,
 90823, 90824,
 90846, 90847
 90862
 96152, 96154,
 97003, 97004
 99201, 99202,
 99212, 99213,
 99241, 99242,
 99304, 99305,
 99307, 99308,
 99324, 99325,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96155
99203,
99214,
99243,
99306
99309,
99326,
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
25
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients or their caregiver(s) who were counseled or referred for counseling regarding
safety concerns within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 6101F: Safety counseling for dementia provided
CPT Category II Code 6102F: Safety counseling for dementia ordered
Denominator
Exceptions
Documentation of medical reason(s) for not counseling regarding safety concerns (eg,
patient at end of life, other medical reason)
 Append modifier to CPT II Code 6102F-1P
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 6101F if patient (or caregiver) counseled regarding safety concerns or report
6102F if patient (or caregiver) was referred for counseling regarding safety concerns.
For the patient with appropriate exception criteria, report 6102F with modifier 1P;
modifiers 2P and 3P may not be reported.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
26
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #8 – Counseling Regarding Risks of Driving
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
27
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:
 90801, 90802
 90804, 90805,
 90810, 90811,
 90816, 90817,
 90823, 90824,
 90846, 90847
 90862
 96152, 96154,
 97003, 97004
 99201, 99202,
 99212, 99213,
 99241, 99242,
 99304, 99305,
 99307, 99308,
 99324, 99325,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
96155
99203,
99214,
99243,
99306
99309,
99326,
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
28
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients or their caregiver(s) who were counseled regarding the risks of driving and the
alternatives to driving at least once within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 6110F: Counseling provided regarding risks of driving and the
alternatives to driving
Denominator
Exceptions
Documentation of medical reason(s) for not counseling regarding the risks of driving (eg,
patient is no longer driving, other medical reason)
 Append modifier to CPT II Code 6110F-1P
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 6110F if patient (or caregiver) was counseled regarding the risks of driving and
alternatives to driving.
For the patient with appropriate exception criteria, report 6110F with modifier 1P;
modifiers 2P and 3P may not be reported.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
29
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #9 – Palliative Care Counseling and Advance Care
Planning
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
30
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:














90801, 90802
90804, 90805,
90810, 90811,
90816, 90817,
90823, 90824,
90846, 90847
90862
96152, 96154,
99201, 99202,
99212, 99213,
99241, 99242,
99304, 99305,
99307, 99308,
99324, 99325,
90806,
90812,
90818,
90826,
96155
99203,
99214,
99243,
99306
99309,
99326,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
99204, 99205
99215
99244, 99245
99310
99327, 99328
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
31
Administrative Claims Specifications
PCPI APPROVED
Dementia



Numerator
99334, 99335, 99336, 99337
99341, 99342, 99343, 99344, 99345
99347, 99348, 99349, 99350
Patients or their caregiver(s) who received 1) comprehensive counseling regarding
ongoing palliation and symptom management and end of life decisions AND 2) have an
advance care plan or surrogate decisions maker in the medical record or documentation
in the medical record that the patient did not wish or was not able to name a surrogate
decision maker or provide an advance care plan within two years of initial diagnosis or
assumption of care
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 4350F: Counseling provided on symptom management, end of
life decisions, and palliation
CPT Category II Code 1123F: Advanced care planning discussed and documented
advanced care plan or surrogate decision maker documented in the medical record
CPT Category II Code 1124F: Advanced care planning discussed and documented in the
medical record, patient did not wish or was not able to name a surrogate decision maker
or provide an advanced care plan
Denominator
Exceptions
None
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 4350F if patient (or caregiver) received comprehensive counseling regarding
ongoing palliation and symptom management and end of life decisions. In addition,
report 1123F or 1124F, to indicate advance care planning discussion and decision
regarding an advance care plan.
There are no performance exceptions for this measure; modifiers 1P, 2P or 3P may not
be used.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
32
Administrative Claims Specifications
PCPI APPROVED
Dementia
Measure #10 – Caregiver Education and Support
Denominator
(Eligible
Population)
All patients, regardless of age, with a diagnosis of dementia
ICD-9-CM Diagnosis Codes:
Code
Descriptor
Neurosyphilis
094.1
Neurosyphilis, General paresis
Dementias
290.0 Senile dementia, uncomplicated
290.10 Presenile dementia, uncomplicated
290.11 Presenile dementia with delirium
290.12 Presenile dementia with delusional features
290.13 Presenile dementia with depressive features
290.20 Senile dementia with delusional features
290.21 Senile dementia with depressive features
290.3 Senile dementia with delirium
290.40 Vascular dementia, uncomplicated
290.41 Vascular dementia with delirium
290.42 Vascular dementia with delusions
290.43 Vascular dementia with depressed mood
290.8 Other specified senile psychotic conditions
290.9 Unspecified senile psychotic condition
Persistent Mental Disorders due to Conditions Classified Elsewhere
294.10 Dementia in conditions classified elsewhere without
behavioral disturbance
294.11 Dementia in conditions classified elsewhere with behavioral
disturbance
294.20 Dementia, unspecified, without behavioral disturbance
294.21 Dementia, unspecified, with behavioral disturbance
294.8 Other persistent mental disorders due to conditions classified
elsewhere
Other cerebral degenerations
331.0 Alzheimer’s disease
331.11 Pick’s disease
331.19 Other frontotemporal dementia
331.82 Dementia with Lewy bodies
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
33
Administrative Claims Specifications
PCPI APPROVED
Dementia
Denominator
(Eligible
Population)
Continued
ICD-10-CM Diagnosis Codes:
Code
Descriptor
Late Syphilis
A52.17 Symptomatic neurosyphilis, General paresis
Vascular Dementia
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
Dementia in Other Diseases Classified Elsewhere
F02.80 Dementia in other diseases classified elsewhere, without
behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere, with
behavioral disturbance
Unspecified Dementia
F03
Unspecified dementia
Delirium due to Known Physiological Condition
F05
Delirium due to unknown physiological condition
Other Mental Disorders Due to Known Physiological Condition
F06.0 Psychotic disorder with hallucinations due to known
physiological condition
F06.8 Other specified mental disorders due to known physiological
condition
Alzheimer’s Disease
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
Other Degenerative Diseases of Nervous System, Not Elsewhere
Classified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies
AND
CPT® Code:












Numerator
90801, 90802
90804, 90805,
90810, 90811,
90816, 90817,
90823, 90824,
90846, 90847
90862
96154, 96155
97003, 97004
99201, 99202,
99212, 99213,
99241, 99242,
90806,
90812,
90818,
90826,
90807, 90808, 90809
90813, 90814, 90815
90819, 90821, 90822
90827, 90828, 90829
99203, 99204, 99205
99214, 99215
99243, 99244, 99245
Patients whose caregiver(s) were provided with education on dementia disease
management and health behavior changes AND referred to additional resources for
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
34
Administrative Claims Specifications
PCPI APPROVED
Dementia
support within a 12 month period
Please refer to the Measure Set Worksheets for complete numerator definition.
CPT Category II Code 4322F: Caregiver provided with education and referred to
additional resources for support
Denominator
Exceptions
Documentation of medical reason(s) for not providing the caregiver with education on
disease management and health behavior changes or referring to additional sources for
support (eg, patient does not have a caregiver, other medical reason)
 Append modifier to CPT II code 4322F-1P
Additional
CPT Category
II Codes used
to report this
measure
None
Reporting
Instructions
Report 4322F if patient’s caregiver was provided education on disease management and
health behavior changes performed AND referred to additional resources for support.
For the patient with appropriate exception criteria, report 4322F with modifier 1P;
modifiers 2P and 3P may not be reported.
© 2011 American Medical Association. All Rights Reserved.
CPT® Copyright 2010 American Medical Association
35