FIHN PCP
Pod Meeting
April 6, 2017
1
EHR Measure Scores
20.97 Eye
39.11 A1c
Reminder: Customer Service and Claim
based Measure Scores pending
35.48 Eye
20.56 A1c
2
Abstraction concerns
Many patients failed CARE-3 (ACO-39): Documentation of
Current Medications in the Medical Record (49.41%)
• Most commonly due to lack of Route of Administration
details
• Also many prescriptions missing dose and frequency
information
• A similar measure replaces this for 2017 but still uses
definition of a current reconciled medications list
“The medication list should include all medications (prescriptions, overthe-counter, herbals, supplements, etc.) with dose, frequency, route, and
reason for taking it. It is also important to verify whether the patient is
actually taking the medication as prescribed or instructed, as sometimes
this is not the case. “
3
Abstraction concerns
Patients are failing PREV-9 (ACO-16): BMI Screening and
follow-up (82.3%)
• Different parameters based on age: EHR may not alert
differently for 65+
• Age 65 and older BMI >= 23 and < 30
• Age 18-64
BMI >= 18.5 and < 25
• Many elderly patients are underweight per these
parameters and are not receiving plans
• Others are receiving plans to eat fewer calories, low salt,
low fat, etc.- this would count on a report but may be a
concern for appropriateness
4
Abstraction concerns
Patients are failing or being excluded from MH-1 (ACO-40)
at very high rates: Depression Remission at 12 months
(6.7%)
• Not the Depression Screening measure
• Denominator: Age 18+ with dx of major depression or
dysthymia AND an initial PHQ-9 score > 9 during the
encounter
• Numerator: Who achieved remission at 12 months as
demonstrated by a twelve month (+/- 30 days) PHQ-9
score of less than 5
• Denominator exclusions: permanent nursing home
residents, , dx of bipolar, dx of personality disorder
5
Abstraction concerns
FIHN MSSP is just above benchmark for DM Composite:
Hemoglobin A1C Poor Control and Retinal Eye Exam
(31.2%)
• 18-75 with diabetes with A1c >9%; inverse measure
• 18-75 with diabetes who had a retinal or dilated eye
exam by an eye care professional or negative retinal
exam in 12 months prior to measurement period
• These are composed together for the score
6
2017 Primary Focus on:
• Depression Screening (c f/u plan)
• Breast Cancer Screening
• Colorectal Cancer Screening
• Diabetes Composite Measure
(HbA1C + Retinal Exam)
• Depression Remission at 12 Months
7
Changes to MSSP 2017 Quality Measures
8
Medication Reconciliation Post Discharge
DESCRIPTION: The percentage of discharges from any inpatient facility (e.g. hospital,
skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen
within 30 days following discharge in the office by the physician, prescribing practitioner,
registered nurse, or clinical pharmacist providing on-going care for whom the discharge
medication list was reconciled with the current medication list
DEFINITION: Medication Reconciliation –Discharge medications are reconciled with the
most recent medication list in the outpatient medical record. Must include evidence of
medication reconciliation and the date. Any of the following evidence meets criteria:
• Examples on signed documentation
• Current medications with a notation that references the discharge medications (e.g., no changes
in meds since discharge, same meds at discharge, discontinue all discharge meds)
• Current medications with a notation that the discharge medications were reviewed
• Notation: “reconciled the current and discharge meds”
• A current medication list, a discharge medication list and notation that the appropriate
practitioner type reviewed both lists on the same date of service
• Notation that no medications were prescribed or ordered upon discharge
• Document in EHR for quality reporting – check box for “reconciled” or “verified”
• Important Note: Dose, frequency, route and reason for taking must be noted to the
best of the provider’s ability
9
ACO 44: Use of Imaging for Low
Back Pain
Numerator
Denominator
Comments
EHR Documentation
Patients who
received an imaging
study (e.g. plain x-ray,
MRI, CT Scan)
conducted on the
episode start date or
in the 28 days
following.
All patients 18 -50
• Exclusions –
• Measure captured
years of age who had
patients with a
via claims.
an outpatient or ER
low back pain
• Measure reported
encounter with a
diagnosis during
principal diagnosis of
the 180 days prior;
as inverted
low back pain during
patients with
measure (i.e.
the start of the
cancer; recent
higher percentage
measurement period
trauma,
indicates
through 28 days prior
intravenous drug
appropriate
to the end of the
abuse,
treatment
measurement period.
neurological
(proportion for
impairment
• Exceptions - none
whom imaging
studies didn’t
occur)
10
Depression Screening with follow-up
• At least once in 2017- maybe during Annual Wellness Visit OR on Medicare Screening
Questionnaire
• If PHQ-2 is positive, follow up with PHQ-9 and/or Plan
• May consider using z13.89 (encounter for screening of other disorder)
• Document Exclusions: Active dx of depression or bipolar disorder
• Document Exceptions: Refusals
11
Examples of a Follow-up Plan
• Additional evaluation for depression or PHQ-9
• Suicide Risk Assessment
• Referral to a practitioner who is qualified to diagnose
and treat depression
• Pharmacologic interventions (drug therapy)
• Other intervention or follow-up for the diagnosis or
treatment of depression
12
At-Risk Domain MH: Depression
Remission
• Depression Remission – do PHQ-9 for every visit on a
patient with depression or dysthymia; or schedule on a
yearly basis (e.g. at the time of the MC Wellness Visit)
• 2017 Measure Index period 12/01/15-11/30/2016
• Document Exclusions – hospice or palliative care, permanent
nursing home residents, diagnosis of bipolar or personality
disorder
13
NextGen Charting
vs
eClinicalWorks
14
NextGen
15
Documenting Exclusions
16
Exception/Exclusion
documentation
17
Mammogram
• Use Medicare Screening Questionnaire
• Exclusions: Bilateral or two unilateral mastectomies
18
Colorectal Cancer Screening
• Use Medicare Screening Questionnaire
• Encourage FOBT (x3), Flex Sig, Cologuard, Virtual
Colonoscopy for those who refuse Colonoscopy
• Document exclusions: total colectomy or colorectal
cancer
19
NextGen
20
Exclusions
21
Diabetes Composite
• HbA1c (must record date, and be <9 (controlled))
- AND • Current Retinal Exam: Every year for positive
retinopathy, Every 2 years for negative retinopathy
22
23
Eye Exam
Referral &
Fax Form
24
Diabetes Composite – HbA1c
• If send out – please order test BEFORE office visit (to
discuss results of the test)
• Medicare allows every 6 months for IGT, every 3 months
for Diabetes
• If pt consistently remains >9, consider Endocrine
consultation
25
Medication Reconciliation Post
Discharge
• Medication Reconciliation Post-Discharge
• Should include all medication including prescriptions,
OTCs, vitamins, and supplements
• Should include strength, dose, route, timing (sig)
• (SEE SUPERUSER POD SLIDE)
26
NextGen
27
Fall Screening
• Must ask the patient: Have you had two (2) or more falls
in the past year, or one (1) or more with an injury?
• (A) Part of Annual Wellness Visit exam (AWV HRA #17)
- OR (B) Consider using the Medicare Screening Questionnaire
for all Medicare patients
28
NextGen Fall Screening
29
NextGen Fall Screening
30
Fall Screening Exceptions
31
Additional Plan or Exclusions
32
Flu Immunization
• Flu season runs from Fall (8/1/15) to Spring (3/31/16) –
already done for 2016 report: CAN go back and record
refusals and allergies
• Record date if / when given in EMR
• If done at a pharmacy / elsewhere record the closest date
possible (eg October 1st) and note that it was given there
• Vaccine Registry can be accessed:
www.mdimmunet.org (410-767-6606)
33
Flu Immunization Exceptions
• Record Vaccine refusals (make sure your EMR has a
“refusal” element if patient declines the shot)
• Also record if the patient is allergic to flu shots (list
under “Allergies”), or cannot receive it due to other
medical reasons
• (Can also list other System issues, such as the vaccine is
not available, if appropriate.)
34
NextGen
Exclusions may be documented by selecting “Not Administered” and
selecting the reason.
35
Exceptions
36
Pneumococcal Vaccination
No Exclusions
• Give Prevnar-13 or Pneumovax to all pts > 65yo
• No exceptions or exclusions (for vaccination refusal)
• If given this year, must document specific type
• May use state Vaccine Registry
www.mdimmunet.org (410-767-6606)
37
Pneumococcal Vaccination
• It is encouraged for all practices to give the vaccine
• Cost (10 doses per box):
Pneumovax (90732) - $76.53 per dose
Prevnar-13 (90670) - $159.57 per dose
• Medicare Reimbursement:
Pneumovax (90732) - $88.80
Prevnar-13 (90670) - $177.44
Immun Single Injection (G0009) – $25.67
38
BMI (Body Mass Index)
BMI (65yo and older)
•If BMI < 23
write a plan to increase weight
•If BMI 23-30
no plan needed; weight satisfactory
•If BMI > 30
write a plan to decrease weight
•(for under 65yo BMI’s should be >18.5 and < 25;
document if patient refuses plan)
39
NextGen
40
Exclusions
41
Tobacco Use
•Must Document Smoking and Smokeless tobacco
use/non-use
•Offer counseling
•Refer to an established smoking cessation program – FMH
Outpatient Cessation Program (240-566-3622)
•With proper documentation can bill in office 99406
(Smoking and tobacco use cessation counseling visit; 3-10
minutes) or 99407 (>10 minutes); use modifier 25
42
NextGen
43
Exceptions/Exclusions
44
HTN Control
• Hypertension Control – must keep BP < 140 / 90; one
exclusion is ESRD
45
IVD
• IVD – document baby ASA, anti-thrombotics.
No
exceptions
46
Statin Therapy for Prevention
and Treatment of Cardiovascular
Disease
47
Exclusions
48
Exceptions
49
Questions
50