2016 Clinical Quality Measure Cheat Sheets
CMS 2 NQF 0418 - PREVENTIVE CARE AND SCREENING: SCREENING FOR CLINICAL DEPRESSION AND FOLLOW-UP PLAN
[PPH] ..................................................................................................................................................................................................... 3
CMS 22 NQF TBD - PREVENTIVE CARE AND SCREENING: SCREENING FOR HIGH BLOOD PRESSURE AND FOLLOW-UP
DOCUMENTED [PPH] ............................................................................................................................................................................ 7
CMS 52 NQF 0405 - HIV/AIDS: PNEUMOCYSTIS JIROVECI PNEUMONIA (PCP) PROPHYLAXIS [CPE] .............................................. 16
CMS 56 / NQF TBD – FUNCTIONAL STATUS ASSESSMENT FOR HIP REPLACEMENT [PFE]............................................................ 20
CMS 62 NQF 0403 - HIV/AIDS: MEDICAL VISIT [CPE] .......................................................................................................................... 24
CMS 65 NQF TBD - HYPERTENSION: IMPROVEMENT IN BLOOD PRESSURE [CPE] ........................................................................ 26
CMS 66 / NQF TBD – FUNCTIONAL STATUS ASSESSMENT FOR KNEE REPLACEMENT [PFE] ....................................................... 29
CMS 68 NQF 0419 - DOCUMENTATION OF CURRENT MEDICATIONS IN THE MEDICAL RECORD [PS] .......................................... 33
CMS 69 NQF 0421 - PREVENTIVE CARE AND SCREENING: BODY MASS INDEX (BMI) SCREENING AND FOLLOW-UP [PPH] ........ 36
CMS 75 NQF TBD - CHILDREN WHO HAVE DENTAL DECAY OR CAVITIES [CPE] ............................................................................. 42
CMS 90 NQF TBD - FUNCTIONAL STATUS ASSESSMENT FOR COMPLEX CHRONIC CONDITIONS [PFE] ...................................... 44
CMS 117 / NQF 0038 – CHILDHOOD IMMUNIZATION STATUS [PPH] .............................................................................................. 47
CMS 122 / NQF 0059 - DIABETES: HEMOGLOBIN A1C POOR CONTROL [CPE] ................................................................................. 55
CMS 123 NQF 0056 - DIABETES: FOOT EXAM [CPE] .......................................................................................................................... 57
CMS 124 / NQF 0032 - CERVICAL CANCER SCREENING [CPE] ......................................................................................................... 60
CMS 127 NQF 0043 - PNEUMONIA VACCINATION STATUS FOR OLDER ADULTS [CPE] .................................................................. 62
CMS 130 NQF 0034 - COLORECTAL CANCER SCREENING [CPE] .................................................................................................... 64
CMS 131 / NQF 0055 - DIABETES: EYE EXAM [CPE] ........................................................................................................................... 67
CMS 132 NQF 0564 - CATARACTS: COMPLICATIONS WITHIN 30 DAYS FOLLOWING CATARACT SURGERY REQUIRING
ADDITIONAL SURGICAL PROCEDURES [PS] .................................................................................................................................... 69
CMS 133 / NQF 0565 - CATARACTS: 20/40 OR BETTER VISUAL ACUITY WITHIN 90 DAYS FOLLOWING CATARACT SURGERY [CPE]
............................................................................................................................................................................................................ 72
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CMS 134 / NQF 0062 - DIABETES: URINE PROTEIN SCREENING [CPE] ............................................................................................ 75
CMS 135 NQF 0081 - HEART FAILURE (HF): ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITOR OR ANGIOTENSIN
RECEPTOR BLOCKER (ARB) THERAPY FOR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVSD) [CPE] ................................ 78
CMS 138 NQF 0028 - PREVENTIVE CARE AND SCREENING: TOBACCO USE: SCREENING AND CESSATION INTERVENTION
[PPH] ................................................................................................................................................................................................... 83
CMS 139 NQF 0101 - FALLS: SCREENING FOR FUTURE FALL RISK [PS] .......................................................................................... 87
CMS 142 NQF 0089 - DIABETIC RETINOPATHY: COMMUNICATION WITH THE PHYSICIAN MANAGING ONGOING DIABETES CARE
[CPE] ................................................................................................................................................................................................... 90
CMS 143 / NQF 0086 - PRIMARY OPEN-ANGLE GLAUCOMA (POAG): OPTIC NERVE EVALUATION [CPE] ....................................... 95
CMS 144 NQF 0083 - HEART FAILURE (HF): BETA-BLOCKER THERAPY FOR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION
(LVSD) [CPE] ....................................................................................................................................................................................... 99
CMS 145 NQF 0070 - CORONARY ARTERY DISEASE (CAD): BETA-BLOCKER THERAPY—PRIOR MYOCARDIAL INFARCTION (MI)
OR LEFT VENTRICULAR SYSTOLIC DYSFUNCTION (LVEF <40%) [CPE] ........................................................................................ 104
CMS 147 NQF 0041 - PREVENTIVE CARE AND SCREENING: INFLUENZA IMMUNIZATION [PPH] ................................................... 110
CMS 148 / NQF 0060 - HEMOGLOBIN A1C TEST FOR PEDIATRIC PATIENTS [CPE]........................................................................ 113
CMS 153 NQF 0033 - CHLAMYDIA SCREENING FOR WOMEN [PPH] ............................................................................................... 115
CMS 155 / NQF 0024 - WEIGHT ASSESSMENT AND COUNSELING FOR NUTRITION AND PHYSICAL ACTIVITY FOR CHILDREN
AND ADOLESCENTS [PPH]............................................................................................................................................................... 119
CMS 156 NQF 0022 - USE OF HIGH-RISK MEDICATIONS IN THE ELDERLY [PS] ............................................................................. 124
CMS 158 NQF 0608 - PREGNANT WOMEN THAT HAD HBSAG TESTING [CPE] ............................................................................... 126
CMS 163 NQF 0064 - DIABETES: LOW DENSITY LIPOPROTEIN (LDL) MANAGEMENT [CPE] ......................................................... 129
CMS 165 / NQF 0018 – CONTROLLING HIGH BLOOD PRESSURE [CPE].......................................................................................... 131
CMS 166 / NQF 0052 - USE OF IMAGING STUDIES FOR LOW BACK PAIN [EUHR] .......................................................................... 133
CMS 167 / NQF 0088 - DIABETIC RETINOPATHY: DOCUMENTATION OF PRESENCE OR ABSENCE OF MACULAR EDEMA AND
LEVEL OF SEVERITY OF RETINOPATHY [CPE] ............................................................................................................................... 136
CMS 182 NQF 0075 - ISCHEMIC VASCULAR DISEASE (IVD): COMPLETE LIPID PANEL AND LDL CONTROL [CPE]........................ 140
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2016 Clinical Quality Measure Cheat Sheet
CMS 2 NQF 0418 - Preventive Care and Screening: Screening for Clinical
Depression and Follow-Up Plan [PPH]
Percentage of patients aged 12 years and older screened for clinical depression on the date of
the encounter using an age appropriate standardized depression screening tool AND if positive,
a follow-up plan is documented on the date of the positive screen.
Initial Patient Population: All patients aged 12 years and older before the beginning of the
measurement period with at least one eligible encounter during the measurement period.
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients with an active diagnosis for Depression or Bipolar
Disorder
Numerator: Patients screened for clinical depression on the date of the encounter using an
age appropriate standardized tool AND if positive, a follow-up plan is documented on the
date of the positive screen
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. Open the Vitals app click on either the Positive or Negative radio button in the Depression
Screening section, during the measurement period.
If negative is selected, then jump down to Step #4.
If positive is selected then one (1) of the following should be recorded <=1 day after the
entry of the depression screening result:
•
•
•
•
•
Additional evaluation for depression – record in the Vitals app
Referral for Depression – record in the Vitals app
Follow-up for depression – record in the Vitals app
Depression medications – record in the Vitals app and then prescribe a medication via
the Rx module
Suicide Risk Assessment – record in the Vitals app and then add a Completed Order
(procedure) via the Orders/Results app
a. Click on the Post-screening plan link.
b. The Depression Screening window appears.
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c. Click on the desired option and then click on the Select & Close button.
4. Document the Start Time and End Time for the assessment in the Vitals app.
5. Click on the Save & Close button on the Vitals app.
6. Prescribe a medication in the Rx module, if appropriate.
7. Document “Suicide Risk” as a Completed order (procedure) via the Orders/Results app, if
appropriate.
8. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exceptions:
Record that there is a medical/system reason for not screening a patient for depression within
the Vitals app during the measurement period.
1. Click on the Reason for Decline button
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2. Click on the down arrow next to the Depression Screening plan. A menu appears; click on
a medical reason to select it.
3. Then click on the OK button
Denominator Exclusion:
The patient has an active diagnosis of either “Bipolar Disorder” or “Depression Diagnosis” within
the Diagnoses App which has an earlier start date than of the screening date.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 22 NQF TBD - Preventive Care and Screening: Screening for High
Blood Pressure and Follow-Up Documented [PPH]
Percentage of patients aged 18 years and older seen during the reporting period who were
screened for high blood pressure AND a recommended follow-up plan is documented based on
the current blood pressure (BP) reading as indicated.
Initial Patient Population: Percentage of patients aged 18 years and older before the start
of the measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patient has an active diagnosis of hypertension
Numerator: Patients who were screened for high blood pressure AND a recommended
follow-up plan is documented as indicated if the blood pressure is pre-hypertensive or
hypertensive
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. Record the patient’s systolic and diastolic BP within the Vitals app.
Note: Based on the BP reading date in regards to the encounter date, the BP reading could
be the first or second reading.
4. If the result is:
Normal - If the BP is normal then nothing more is required.
Pre-Hypertensive - If it is the first reading of the pre-hypertensive BP then the following
must be recorded:
•
Either a referral to another provider or PCP; or a follow up visit within a year.
–AND–
•
A plan for the one of the following:
• Lifestyle recommendation
• Weight reduction
• Dietary recommendations
• Physical activity
• Moderation of ETOH consumption
a. To record a referral and/or a plan, click on the Post-screening plan link.
b. And select from the Add Plan list.
Use the scroll bar to locate the
referral options.
Click on the desired option to select
it and then click on the Select &
Close button.
Note: You can select multiple items,
e.g. Exercise counseling and Diet
education.
c. Click on the button Save & Close button on the Vitals app.
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•

Note: The most recent vital signs display on the Dashboard. An indication of whether or
not the BP has been recorded can be found on the iDash.
If the BP has been recorded but no Post-screening plan selected, users will see this
icon:
If the BP has been recorded and the Post-screening has been selected, users will see this
icon:
In the Vitals history display; you can hover your mouse over the
appears with the Post-screening plan selections.
icon, and a pop-up
Click on the x button to close the Vitals history.
Hypertensive - If it is the first hypertensive reading of the BP then the following must be
recorded (follow instructions in previous section):
•
Either a referral to another provider or PCP; or a follow up visit within a year.
–AND–
•
A plan for the one of the following:
• Lifestyle recommendation
• Weight reduction
• Dietary recommendations
• Physical activity
• Moderation of ETOH consumption
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If it is the second hypertensive reading of the BP then the following needs to be recorded:
•
Either a referral to another provider or PCP, or a plan for the one of the following:
• Lifestyle recommendation
• Weight reduction
• Dietary recommendations
• Physical activity
• Moderation of ETOH consumption
–AND–
•
An order of one of the following:
•
Record a BP drug within the Rx module
–OR–
•
Order an appropriate lab test for hypertension within the Orders/Results app.
Note: If you are ordering a lab test to meet this measure, the lab order being placed needs
be associated with an appropriate LOINC code from the CMS provided value set.
Instructions on how to map the appropriate code to accurately report this measure can be
found in Appendix B and C of the SRS v9 Orders and Results Manual (Article 937 in the
SRS Knowledgebase).
–OR–
•
Order an EKG within the Orders/Results app (either Completed or Future).
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
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The patient has active diagnosis of “Hypertension” recorded within the Diagnoses app.
Denominator Exceptions:
Exception Scenario 1: Patient Declines Blood Pressure Screening:
The reason for not screening the patient for blood pressure should be recorded within the Vitals
app:
1. Click on the Reason for decline button.
2. Click on the down arrow next to the BP field and click on a reason to select it.
Click on the Save&Close button on the Vitals app.

Note: If the patient declines the BP screening the below icon will be visible on the iDash:
Exception Scenario 2: Patient Declines Post-Screening Plan Intervention:
The reason for not screening the patient for blood pressure should be recorded within the PostScreening Plan link in the Vitals app:
1. To select an Intervention click on the Post Screening Plan link per current behavior to view
the ‘Add Plan’ window:
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2. Select an Intervention by clicking on an Intervention
3. To decline an Intervention, select the Checkbox in the Reason for Decline Column to view
the Reason for Decline Pop Up and select the appropriate reason
4. Click Ok to select the desired Reason for Decline
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5. Click Select & Close to select the Intervention and Reason for Decline
6. Upon Save & Close on the Vitals App the Intervention and Reason for Decline are saved
Exception Scenario 3: Patient Declines Medication Treatment Intervention:
1. Users should launch the Rx Decline App
2. Click the Prescriptions Tab
3. Search for the appropriate BP drug and the corresponding Reason for Decline
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4. Click Save & Close to record the exclusion for CQM 22
Exception Scenario 4: Patient Declines Diagnostic Study:
1. Users should launch CPOE, select the Diagnosis and add the Appropriate Diagnostic
Study as a Completed Procedure
2. Launch the Order History Screen, select the created order and click the “Update Status”
button
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3. Update the Status to ‘Not Performed, Patient Reason’ and Select ‘OK’ on Update Status
Screen
4. Add an ‘Order Tracking Note’ and select ‘Save’ in the Update Order Status screen
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015. .
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2016 Clinical Quality Measure Cheat Sheet
CMS 52 NQF 0405 - HIV/AIDS: Pneumocystis jiroveci pneumonia (PCP)
prophylaxis [CPE]
Percentage of patients aged 6 weeks and older with a diagnosis of HIV/AIDS who were
prescribed Pneumocystis jiroveci pneumonia (PCP) prophylaxis.
Initial Patient Population:
Denominator 1: All patients aged 6 years and older with a diagnosis of HIV/AIDS and a CD4
count below 200 cells/mm3 who had at least two visits during the measurement year, with at
least 90 days in between each visit
Denominator 2: All patients aged 1-5 years of age with a diagnosis of HIV/AIDS and a CD4
count below 500 cells/mm3 or a CD4 percentage below 15% who had at least two visits
during the measurement year, with at least 90 days in between each visit
Denominator 3: All patients aged 6 weeks to 12 months with a diagnosis of HIV who had at
least two visits during the measurement year, with at least 90 days in between each visit
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator
Numerator 1: Patients who were prescribed pneumocystis jiroveci pneumonia (PCP)
prophylaxis within 3 months of CD4 count below 200 cells/mm3
Numerator 2: Patients who were prescribed pneumocystic jiroveci pneumonia (PCP)
prophylaxis within 3 months of CD4 count below 500 cells/ mm3 or a CD4 percentage below
15%
Numerator 3: Patients who were prescribed Pneumocystic jiroveci pneumonia (PCP)
prophylaxis either within a day or at the time of HIV diagnosis
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
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Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: The patient should be seen for a second encounter of “HIV Visit” during the
measurement period. The encounter should be >= 90 days after the first encounter.
3. The patient has an active diagnosis of “HIV” entered within the Diagnoses app before or
during the measurement period.
Note: For Denominator 3 only, it should be the first occurrence of the HIV diagnosis before
or during the measurement period.
4. The patient should have a lab result recorded in the Orders/Results app for:
Denominator 1
CD4+ Count (result <200 per mm3). The result should have been recorded < 9 month(s)
ends after the start of the measurement period.
–OR–
Denominator 2
The patient should either have a lab result recorded in the Results app for CD4+ Count
(result <500 per mm3) or CD4+ Percentage (result < 15 %). The result should have been
recorded <9 month(s) ends after the start of the measurement period.
–OR–
Denominator 3
No CD4+ Count lab result entered.
Note: This CQMrequires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
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5. The following should be recorded within the Rx module:
Numerator 1
A prescription for “Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis”; prescribed <=3
months of CD4 count below 200 cells/mm3
–OR–
All of the following:
•
A prescription for “Dapsone and pyrimethamine; prescribed <=3 months after end of the
lab test.
•
A prescription for “Leucovorin”. The order should have been placed <= 3 months after
end of the lab test.
•
And one of the following:
• A prescription for “Leucovorin” which should be concurrent with the prescription order
of “Dapsone and pyrimethamine”.
–OR–
•
An active prescription for “Dapsone and pyrimethamine” < 1 day started before or
during when the order for “Leucovorin” was placed.
–OR–
•
An active prescription for “Leucovorin” < 1 day started before or during when the
order for “Dapsone and pyrimethamine” was placed.
Numerator 2:
A prescription for “Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis”, prescribed <= 3
months starts of CD4 count below 500 cells/ mm3 or a CD4 percentage below 15%
Numerator 3:
A prescription for “Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis”; which should
have been prescribed when the first occurrence of the “HIV” diagnosis was recorded.
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6. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exceptions:
Denominator 1:
The patient will be excluded from the denominator if a second result for the lab test “CD4+
Count” is >= 200 per mm3. The result should have been recorded <= 3 months after the first lab
result is recorded within the Orders/Results app.
Denominator 2:
The patient will be excluded from the denominator if one of the following is recorded within the
Orders/Results app:
•
A second result for the lab test “CD4+ Count” is >= 500 per mm3. The result should have
been recorded <= 3 months after the first lab result of CD4+ count is recorded.
–OR–
•
A second result for the lab test “CD4+ Percentage” is >=15%. The result should have
been recorded <= 3 months after the first lab result of CD4+ percentage is recorded.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 56 / NQF TBD – Functional Status Assessment for Hip Replacement
[PFE]
Initial Patient Population: Adults aged 18 and older with a primary total hip arthroplasty
(THA) within the 12 month period that begins 180 days before the start of the measurement
period and ends 185 days after the start of the measurement period and who had an
outpatient encounter not more than 180 days prior to procedure, and at least 60 days and
not more than 180 days after THA procedure.
Denominator: Equals initial patient population
Denominator Exclusions: Patients with multiple trauma at the time of the total hip
arthroplasty or patients with severe cognitive impairment
Numerator: Patients with patient reported functional status assessment results (e.g., VR-12,
VR-36, PROMIS-10-Global Health, PROMIS-29, HOOS) not more than 180 days prior to the
primary THA procedure, and at least 60 days but not more than 180 days after THA
procedure.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: The patient should have two encounters with appropriate codes recorded within the Visit
Type app:
•
The first encounter should be recorded <= 180 days before the date of the
procedure.
•
The second encounter should be recorded between 60 to 180 days after the date of the
procedure.
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3. Add a completed order for the procedure “total hip arthroplasty” using the Orders/Results
app.
Note: The procedure should include the order start date / time and completion date / time.
Procedures recorded <= 180 days before the start of the measurement period or <= 185
days after the start of the measurement period will be counted toward the current year’s
reporting
When entering a completed order, you can adjust the Order Date / time and the
Disposition (completed date / time) by clicking on those items in the Details panel.
Click on the text to change the date and time!
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If you click on the Order Date text, the Order Date dialogue box appears.
Type a different date in the Order Date field or
use the calendar to select a different date.
Type in a different time, if desired.
Click on the OK button.
If you click on the Disposition text, the Order Disposition dialogue box appears.
Type a different date in the Completed
Date field.
Type in a different time, if desired.
To change the Order Disposition, click
on the down arrow and select from the
list.
Click on the OK button.
–AND–
4. The patient should have two functional status assessment scores and the associated
assessment form recorded in the Vitals app using the Hip Assessment Score fields.
Type score here
Select assessment form here
a. The first score should be recorded <= 180 days before the order date of the procedure in
the text box. Click on the down arrow to select the appropriate assessment form.
b. The second score should be recorded between 60 to 180 days after the order date of the
procedure. Click on the down arrow to select the appropriate assessment form.
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5. Click on the Save & Close button on the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
The patient can be excluded from the denominator if they have multiple trauma or severe
dementia recorded in their chart.
•
The patient needs to have at least 2 resolved diagnoses of “Fracture – Lower Body”
recorded within the Diagnoses app to be excluded. The 2 entries should happen < 1
day before the order date of the procedure and >= 1 hours after the order date/time of
the procedure,
–OR–
•
The patient needs to have an active diagnosis of “Severe Dementia” recorded within the
Diagnoses app. The entry should have been before or during the measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 62 NQF 0403 - HIV/AIDS: Medical Visit [CPE]
Percentage of patients, regardless of age, with a diagnosis of HIV/AIDS with at least two
medical visits during the measurement period with a minimum of 90 days between each visit.
Initial Patient Population: All patients, regardless of age, with a diagnosis of HIV/AIDS
seen within a 12 month period
Denominator: Equals initial patient population
Denominator Exclusions: None
Numerator: Patients with at least two medical visits during the measurement period with a
minimum of 90 days between each visit
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: This measure requires two encounters; the 2nd encounter should be >= 90 days from
the first encounter.
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3. The patient has an active diagnosis of “HIV” recorded in the Diagnoses app before or
during the measurement period
4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 65 NQF TBD - Hypertension: Improvement in Blood Pressure [CPE]
Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood
pressure improved during the measurement period.
Initial Patient Population: All patients aged 18-85 years of age, who had at least one
outpatient visit in the first six months of the measurement year, who have a diagnosis of
essential hypertension documented during that outpatient visit, and who have uncontrolled
baseline blood pressure at the time of that visit
Denominator: Equals Initial Patient Population
Denominator Exclusions: Exclude from the denominator all patients with evidence of endstage renal disease (ESRD) on or prior to December 31 of the measurement year.
Documentation of dialysis or kidney transplant also meets the criteria for evidence of ESRD.
Exclude from the denominator all patients with a diagnosis of pregnancy during the
measurement year.
Numerator: Patients whose follow-up blood pressure is at least 10 mmHg less than their
baseline blood pressure or is adequately controlled.
If a follow-up blood pressure reading is not recorded during the measurement year, the
patient’s blood pressure is assumed “not improved.”
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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Note: This measure requires two encounters; the 2nd encounter should be >= 6 months
from the first encounter.
Data Entry for FIRST encounter:
3. The patient has an active diagnosis of “Hypertension” entered within the Diagnoses app.
4. The patient has a systolic BP reading of >= 140 entered within the Vitals app.
–AND–
Data Entry for SECOND encounter:
The patient’s current systolic BP reading is entered within the Vitals app. If the reading is <
140 or the delta between the previous reading and current reading is >= 10, then it means
there is improvement in patient’s hypertension.
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
The patient would be excluded from the measure if they have one of the following:
•
“Kidney Transplant” recorded in the Orders/Results app before or during the
measurement period.
•
“Hemodialysis” recorded in the Orders/Results app before or during the measurement
period.
•
“Peritoneal Dialysis” recorded in the Orders/Results app before or during the measurement
period.
•
Active diagnosis of “Pregnancy” recorded in the Diagnoses app which starts before or
during the measurement period.
•
Active diagnosis of “End State Renal Disease” recorded in the Diagnoses app which starts
before or during the measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 66 / NQF TBD – Functional Status Assessment for Knee
Replacement [PFE]
Percentage of patients aged 18 years and older with primary total knee arthroplasty (TKA) who
completed baseline and follow-up (patient-reported) functional status assessments.
Initial Patient Population: Adults, aged 18 and older, with a primary total knee arthroplasty
(TKA) within the 12 month period that begins 180 days before the start of the measurement
period and ends 185 days after the start of the measurement period and who had an
outpatient encounter not more than 180 days prior to procedure, and at least 60 days and not
more than 180 days after TKA procedure.
Denominator: Equals initial patient population
Denominator Exclusions: Patients with multiple traumas at the time of the total knee
arthroplasty or patients with severe cognitive impairment
Numerator: Patients with patient reported functional status assessment results (e.g., VR-12,
VR-36, PROMIS-10 Global Health, PROMIS-29, KOOS) not more than 180 days prior to the
primary TKA procedure, and at least 60 days and not more than 180 days after TKA
procedure
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: The patient should have two encounters with appropriate codes recorded within the Visit
Type app:
•
The first encounter should be recorded <= 180 days before the date of the
procedure.
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•
The second encounter should be recorded between 60 to 180 days after the date of the
procedure.
3. Add a completed order for the procedure “total knee arthroplasty” using the Orders/Results
app.
Note: The procedure should include the order start date & time and completion date & time.
Procedures recorded <= 180 days before the start of the measurement period or <= 185
days after the start of the measurement period will be counted toward the current year’s
reporting
When entering a completed order, you can adjust the Order Date / time and the
Disposition (completed date / time) by clicking on those items in the Details panel.
Click on the text to change the date and time!
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If you click on the Order Date text, the Order Date dialogue box appears.
Type a different date in the Order Date field or
use the calendar to select a different date.
Type in a different time, if desired.
Click on the OK button.
If you click on the Disposition text, the Order Disposition dialogue box appears.
Type a different date in the Completed
Date field.
Type in a different time, if desired.
To change the Order Disposition, click
on the down arrow and select from the
list.
Click on the OK button.
–AND–
4. The patient should have two functional status assessments recorded in the Vitals app using
the Knee Assessment Score fields.
Type score here
Select assessment form here
a. The first score should be recorded <= 180 days before the order date of the procedure in
the text box. Click on the down arrow to select the appropriate assessment form.
b. The second score should be recorded between 60 to 180 days after the order date of the
procedure. Click on the down arrow to select the appropriate assessment form.
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5. Click on the Save & Close button on the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
The patient can be excluded from the denominator if they have multiple trauma or severe
dementia recorded in their chart.
•
The patient needs to have at least 2 resolved diagnoses of “Fracture – Lower Body”
recorded within the Diagnoses app to be excluded. The 2 entries should happen < 1
day before the order date of the procedure and >= 1 hours after the order date/time of
the procedure,
–OR–
•
The patient needs to have an active diagnosis of “Severe Dementia” recorded within the
Diagnoses app. The entry should have been before or during the measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 68 NQF 0419 - Documentation of Current Medications in the
Medical Record [PS]
Percentage of specified visits for patients aged 18 years and older for which the eligible
professional attests to documenting a list of current medications to the best of his/her
knowledge and ability. This list must include ALL prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name,
dosage, frequency and route of administration.
Initial Patient Population: All visits occurring during the 12 month reporting period for
patients aged 18 years and older before the start of the measurement period
Denominator: Equals Initial Patient Populations
Denominator Exclusions: None
Numerator: Eligible professional attests to documenting a list of current medications to the
best of his/her knowledge and ability. This list must include ALL prescriptions, over-thecounters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain
the medications’ name, dosages, frequency and route of administration.
Note: This must be recorded for each encounter.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. Enter all medications that the patient is currently taking into the Rx module.
Include the route and frequency for a drug that is entered as historical by adding Patient
Instructions.
Note: In situations where you cannot create valid instructions, then enter the route and
frequency in the Notes field. Right-click on the drug that is added as historical and click
on Drug Details to enter the notes.
If the drug does not exist in the database it should be added as a custom drug in the SRS
Administration module and then added to the patient chart.
4. Once all the medications are entered, click in the Current Meds Documented checkbox
located under the Patient Drug History.
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exception:
The user should be in context of an encounter prior to selecting the reason for decline.
Record the medical reason for not obtaining the current meds:
1.
Click on the “Decline” icon on the Rx History app
2. The Reason for Decline dialogue box appears; it defaults to the current Date/Time.
3. Click on the appropriate reason within the Current Meds tab to select it. (Note: Ignore the
Prescription tab; it is used for other Clinical Quality Measures!)
4. Click on the Save & Close button.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 CQM Cheat Sheets–02_01_16
2016 Clinical Quality Measure Cheat Sheet
CMS 69 NQF 0421 - Preventive Care and Screening: Body Mass Index
(BMI) Screening and Follow-Up [PPH]
Percentage of patients aged 18 years and older with a BMI documented during the current
encounter or during the previous six months, AND when the BMI is outside of normal
parameters, follow-up is documented during the encounter or during the previous six months of
the encounter.
Normal Parameters:
Age 65 years and older BMI => 23 and < 30
Age 18 – 64 years BMI => 18.5 and < 25
Initial Patient Population: There are two (2) Initial Patient Populations for this measure
Initial Patient Population 1: All patients 18 through 64 years on the date of the encounter
with at least one eligible encounter during the measurement period NOT INCLUDING
encounters where the patient is receiving palliative care, refuses BMI measurement, the
patient is in an urgent or emergent medical situation where time is of the essence and to
delay treatment would jeopardize the patient’s health status, or there is any other reason
documented in the medical record by the provider explaining why BMI measurement was
not appropriate.
Initial Patient Population 2: All patients 65 years of age and older on the date of the
encounter with at least one eligible encounter during the measurement period NOT
INCLUDING encounters where the patient is receiving palliative care, refuses BMI
measurement, the patient is in an urgent or emergent medical situation where time is of the
essence and to delay treatment would jeopardize the patient’s health status, or there is any
other reason documented in the medical record by the provider explaining why BMI
measurement was not appropriate.
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients who are pregnant.
Numerator: Patients with a documented calculated BMI during the encounter or during the
previous six months, AND when the BMI is outside of normal parameters, follow-up is
documented during the encounter or during the previous six months of the current
encounter.
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To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. If the patient is under palliative care, record it in the Orders/Results app, and skip to step 8
below.
4. If the patient refuses to be screened for BMI – or there is a medical or other reason the
provider would like to document not recording the BMI – open the Vitals app and click on
the Reason for decline button.
a. The Reason for Decline dialogue box appears. Click on the down arrow next to the
Wt/BMI field.
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b. A menu appears, click on the desired option to select it.
c. Then click on the OK button.
d. The fields for Weight are grayed out, preventing data entry.
e. Click on the Save & Close button on the Vitals app and skip to step 8 below.

Note: If the patient declines the BMI screening the below icon will be visible on the iDash:
5. Record the patient’s Height and Weight in the Vitals app; the BMI is displayed.
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Note: This should be recorded during the encounter or during the previous six months.
If the patient’s BMI falls within the normal parameters for the patient’s age, click on the
Save & Close button on the Vitals app and skip to step 8 below.
6. If the patient’s BMI falls outside the normal parameters for the patient’s age and the patient
is not excluded then one of the following should be recorded prior to or during the
encounter:
•
A post screening plan:
Click on the Post Screening Plan link on the BMI line item within the Vitals app
And select from the Add Plan list.
Use the scroll bar to locate the
desired option.
Click on the desired option to
select it and then click on the
Select & Close button.
Note: You can select multiple
Click on the Save & Close button on the Vitals app.
Note: The most recent vital signs display on the Dashboard. An indication of whether or
not the BP has been recorded can be found on the iDash.
•
If the BMI has been recorded but no Post-screening plan selected, users will see this
icon:
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
If the BMI has been recorded and the Post-screening has been selected, users will see
this icon:
–OR–
•
•
An appropriate medication (for overweight or underweight) was prescribed using the Rx
module.
—OR—
(Optional) If the patient is overweight or underweight record the diagnosis in the
Diagnoses app with a status of Active.
7. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
If the patient is pregnant, record an Active diagnosis of pregnancy in the Diagnoses app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 CQM Cheat Sheets–02_01_16
2016 Clinical Quality Measure Cheat Sheet
CMS 75 NQF TBD - Children Who Have Dental Decay or Cavities [CPE]
Percentage of children, age 0-20 years, who have had tooth decay or cavities during the
measurement period.
Initial Patient Population: Children, age 0-20 years, with a visit during the measurement
period.
Denominator: Equals initial patient population
Denominator Exclusions: None
Numerator: Children who had cavities or decayed teeth.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient has an active diagnosis of “Dental Caries” that is recorded within the Diagnoses
app before or during the measurement period.
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4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 CQM Cheat Sheets–02_01_16
2016 Clinical Quality Measure Cheat Sheet
CMS 90 NQF TBD - Functional Status Assessment for Complex Chronic
Conditions [PFE]
Percentage of patients aged 65 years and older with heart failure who completed initial and
follow-up patient-reported functional status assessments.
Initial Patient Population: Adults aged 65 years and older who had two outpatient
encounters during the measurement year and an active diagnosis of heart failure.
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients with severe cognitive impairment or patients with an
active diagnosis of cancer.
Numerator: Patients with patient reported functional status assessment results (e.g., VR-12;
VR-36; MLHF-Q; KCCQ; PROMIS-10 Global Health, PROMIS-29) present in the EHR within
two weeks before or during the initial encounter and the follow-up encounter during the
measurement year.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: This measure requires two encounters; the first encounter should happen within the
first 185 days of the measurement period. The last encounter should be at least 30 days but
no more than 180 after the initial encounter.
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3. The patient has an active diagnosis of “Heart Failure” recorded within the Diagnoses app
before or during the measurement period.
4. There should be two (2) functional status assessment scores recorded within the Vitals app
in the text boxes available next to the label of “HF Assessment Score” <= 2 weeks before
or during the occurrence of initial and follow up encounters respectively.
The entry should also include selection of the appropriate functional status assessment
form. Click on the down arrow and select from the list.
5. Capture the start and end time within the Vitals app.
6. Click on the Save & Close button on the Vitals app.
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7. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
The patient has an active diagnosis of “Severe Dementia” entered in the Diagnoses app before
or during the measurement period.
–OR–
The patient has an active diagnosis of “All Cancer” entered in the Diagnoses app before or
during the measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 CQM Cheat Sheets–02_01_16
2016 Clinical Quality Measure Cheat Sheet
CMS 117 / NQF 0038 – Childhood Immunization Status [PPH]
Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis
(DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B
(HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV);
one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their
second birthday.
Initial Patient Population: Children who turn 2 years of age during the measurement period
and who have a visit during the measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Children who have evidence showing they received recommended vaccines,
had documented history of the illness, had a seropositive test result, or had an allergic
reaction to the vaccine by their second birthday
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. Enter the recommended vaccines using the Patient Immunization Powertab.
–OR–
Enter the reaction using the Diagnosis app.
Lab results, where applicable, must be entered using the Orders/Results app.
Note: This CQM requires that a lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
DTap
a. The patient should have the 4th shot of the “DTaP” vaccination with the status of
completed recorded within the Patient Immunizations PowerTab along with the
previous 3 occurrences of the shot and all shots should be administered to the patient
with a minimum of one day or more gap between each occurrence
–AND–
b. The patient should have had the 4 shots of “DTaP” vaccination with the status of
completed recorded for patients who are older than or equal to 42 days but less than or
equal to 2 years of age
–OR–
c. The patient should have one of the following recorded within the Diagnoses app <= 2
years after patients DOB:
• Anaphylactic Reaction to DTaP Vaccine with a status of Active
• Encephalopathy with a status of Active or resolved
IPV
d. The patient should have the 3rd shot of the “IPV” vaccination with the status of completed
recorded within the Patient Immunizations PowerTab along with the previous 2
occurrences of the shot and all shots should be administered to the patient with a
minimum of one day or more gap between each occurrence
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–AND–
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e. The patient should have had the 3 shots of “IPV” vaccination with the status of
completed recorded for patients who are older than or equal to 42 days but less than or
equal to 2 years of age
–OR–
f.
The patient should have one of the following recorded within the Diagnoses app <= 2
years after patients DOB:
• Anaphylactic Reaction to inactivated IPV
• Anaphylactic Reaction to Streptomycin with a status of Active
• Anaphylactic Reaction to Polymyxin with a status of Active
• Anaphylactic Reaction to Neomycin with a status of Active
MMR
a. The patient should have the “MMR” vaccination with the status of completed recorded
within the Patient Immunizations PowerTab within 2 years of age
–OR–
b. The patient should have one of the following recorded in the Diagnoses App:
• Disorders of the Immune System with a status of Active
• HIV with a status of Active
• Malignant Neoplasm of Lymphatic Tissue with a status of Active
• Anaphylactic Reaction to Neomycin with a status of Active
• The following <= 2 years after patients DOB
o Measles with a status of Active or Resolved or lab test result of seropositive for
Measles Antigen Test recorded in the Orders / Results app
–AND–
o Mumps with a status of Active or Resolved or lab test result of seropositive for
Mumps Antigen Test recorded in the Orders / Results app
–AND–
o Rubella with a status of Active or Resolved or lab test result of seropositive for
Rubella Antigen Test recorded in the Orders / Results app
HIB
a. The patient should have the 3rd shot of the “HIB” vaccination with the status of completed
recorded within the Patient Immunizations PowerTab along with the previous 2
occurrences of the shot and all shots should be administered to the patient with a
minimum of one day or more gap between each occurrence
–AND–
b. The patient should have had the 3 shots of “HIB” vaccination with the status of
completed recorded for patients who are older than or equal to 42 days but less than or
equal to 2 years of age
–OR–
c. The patient should have the following recorded within the Diagnoses app <= 2 years
after patients DOB:
• Anaphylactic Reaction to Hemophilus Influenza B (HiB) Vaccine with a status of
Active
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Hepatitis B
a. The patient should have the 3rd shot of the “Hepatitis B” vaccination with the status of
completed recorded within the Patient Immunizations PowerTab along with the
previous 2 occurrences of the shot and all shots should be administered to the patient
with a minimum of one day or more gap between each occurrence
–AND–
b. The patient should have had the 3 shots of “Hepatitis B” vaccination with the status of
completed recorded for patients who are older than or equal to 42 days but less than or
equal to 2 years of age
–OR–
c. The patient should have one of the following recorded within the Diagnoses app <= 2
years after patients DOB:
• Anaphylactic Reaction to Hepatitis B Vaccine with a status of Active
• Anaphylactic Reaction to Common Baker’s Yeast with a status of Active
• Hepatitis B with a status of Active or InActive
• Lab test result of seropositive for Hepatitis B Antigen Test recorded in the Orders /
Results app
VZV
a. The patient should have the “VZV” vaccination with the status of completed recorded
within the Patient Immunizations PowerTab within 2 years of age
–OR–
b. The patient should have one of the following recorded in the Diagnoses app <= 2 years
after patients DOB:
• Disorders of the Immune System with a status of Active
• HIV with a status of Active
• Malignant Neoplasm of Lymphatic Tissue with a status of Active
• Anaphylactic Reaction to Neomycin with a status of Active
• Varicella Zoster with a status of Active, Inactive or Resolved
–OR–
•
Lab test result of seropositive for Varicella Zoster Antigen Test recorded in the
Orders / Results app
PCV
a. The patient should have the 4th shot of the “PCV” vaccination with the status of
completed recorded within the Patient Immunizations PowerTab along with the
previous 3 occurrences of the shot and all shots should be administered to the patient
with a minimum of one day or more gap between each occurrence
– AND–
b. The patient should have had the 4 shots of “PCV” vaccination with the status of
completed recorded for patients who are older than or equal to 42 days but less than or
equal to 2 years of age
–OR–
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c. The patient should have the following recorded within the Diagnoses app <= 2 years
after patients DOB:
• Anaphylactic Reaction to PCV Vaccine with a status of Active
Hepatitis A
a. The patient should have Hepatitis A vaccine administered <= 2 years after patients DOB
–OR–
b. The patient should have one of the following recorded within the Diagnoses app <= 2
years after patients DOB:OR
• Diagnosis Active: Anaphylactic Reaction to hepatitis A Vaccine
• Diagnosis Active: Hepatitis A
• Diagnosis Resolved: Hepatitis A
c. The patient should have a Lab test result: Hepatitis Antigen A (result seropositive)
recorded in the Orders / Results app<= 2 years after patients DOB
Rotavirus
a. The patient should have the 2nd shot of the “Rotavirus (2 dose schedule)” vaccination
with the status of completed recorded within the Patient Immunizations PowerTab
along with the previous 1 occurrence of the shot and all shots should be administered to
the patient with a minimum of one day or more gap between each occurrence
–AND–
b. The patient should have had the 2 shots of “Rotavirus (2 dose schedule)” vaccination
with the status of completed recorded for patients who are older than or equal to 42 days
but less than or equal to 2 years of age
–OR–
c. The patient should have the following recorded in the Diagnoses app <= 2 years after
patients DOB :
• Anaphylactic Reaction to Rotavirus Vaccine with a status of Active
-ORa. The patient should have the 1st shot of the “Rotavirus (3 dose schedule)” vaccination
with the status of completed recorded within the Patient Immunizations PowerTab
along with the 1st shot “Rotavirus (3 dose schedule)” and 1st shot of “Rotavirus (2 dose
schedule)” and all shots should be administered to the patient with a minimum of one
day or more gap between each occurrence
–AND–
b. The patient should have had the 2 shots of “Rotavirus (3 dose schedule)” and 1 shot of
“Rotavirus (2 dose schedule)” vaccination with the status of completed recorded for
patients who are older than or equal to 42 days but less than or equal to 2 years of age
–OR–
c. The patient should have the following recorded in the Diagnoses app <= 2 years after
patients DOB :
• Anaphylactic Reaction to Rotavirus Vaccine with a status of Active
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-ORa. The patient should have the 1st shot of the “Rotavirus (3 dose schedule)” vaccination
with the status of completed recorded within the Patient Immunizations PowerTab
along with the 2 shots “Rotavirus (3 dose schedule)” and all shots should be
administered to the patient with a minimum of one day or more gap between each
occurrence
–AND–
b. The patient should have had the 3 shots of “Rotavirus (3 dose schedule)” vaccination
with the status of completed recorded for patients who are older than or equal to 42 days
but less than or equal to 2 years of age
–OR–
c. The patient should have the following recorded in the Diagnoses app <= 2 years after
patients DOB :
• Anaphylactic Reaction to Rotavirus Vaccine with a status of Active
Influenza
a. The patient should have the 2nd shot of the “Influenza” vaccination with the status of
completed recorded within the Patient Immunizations PowerTab along with the
previous occurrence (1) of the shot and all shots should be administered to the patient
with a minimum of one day or more gap between each occurrence
–AND–
b. The patient should have had the 2 shots the “Influenza” vaccination with the status of
completed recorded for patients who are older than or equal to 180 days but less than or
equal to 2 years of age
–OR–
c. The patient should have one of the following recorded within the Diagnoses App:
• Anaphylactic Reaction to Influenza Vaccine with a status of Active
• Disorders of the Immune System with a status of Active
• HIV with a status of Active
• Malignant Neoplasm of Lymphatic Tissue with a status of Active
• Anaphylactic Reaction to Neomycin with a status of Active
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4. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 CQM Cheat Sheets–02_01_16
2016 Clinical Quality Measure Cheat Sheet
CMS 122 / NQF 0059 - Diabetes: Hemoglobin A1c Poor Control [CPE]
Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0%
during the measurement period.
Initial Patient Population: Patients 18-75 years of age with diabetes with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Numerator: Patients whose most recent HbA1c level (performed during the measurement
period) is >9.0%
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of Diabetes in the Diagnosis app; add it if
necessary.
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4. The patient’s most recent “HbA1c Laboratory Test” has a result recorded in the
Orders/Results app with a value > 9% during the measurement period.
–OR–
The patient does not have a lab test recorded within the Orders/Results app for “HbA1c
Laboratory Test” during the measurement period.
Note: This CQM requires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 123 NQF 0056 - Diabetes: Foot Exam [CPE]
Percentage of patients aged 18-75 years of age with diabetes who had a foot exam during the
measurement period.
Initial Patient Population: Patients 18-75 years of age with diabetes with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Numerator: Patients who received a foot exam (visual inspection with either a sensory
exam or pulse exam) during the measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient has an active diagnosis of “Diabetes” recorded within the Diagnoses app before
or during the measurement period
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4. The patient should have each the following recorded within the Vitals app during the
measurement period:
•
Visual Exam of Foot - Click on the radio button to select either Normal or Abnormal.
–AND–
•
Sensory exam of foot documented using the Monofilament Exam - Click on the radio
button to select either Normal or Abnormal.
–AND–
•
Pulse exam of foot documented using the Posterior Tibial and Dorsalis Pedis - Click
on the radio button to select either Normal or Abnormal; then enter the pulse in the
adjacent fields.
Right Left
Note: Ensure that the Start Time and End Time for the examination are recorded
accurately in the Vitals app.
While recording data within the Vitals app the user must be in context of the encounter
during which the physical exam was performed.
5. Click on the Save & Close button on the Vitals app.
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6. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 124 / NQF 0032 - Cervical Cancer Screening [CPE]
Percentage of women 21-64 years of age, who received one or more Pap tests to screen for
cervical cancer.
Initial Patient Population: Women 23-64 years of age with a visit during the measurement
period
Denominator: Equals Initial Patient Population
Denominator Exclusions: Women who had a hysterectomy with no residual cervix
Numerator: Women with one or more Pap tests during the measurement period or the two
years prior to the measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. The patient’s lab test for “Pap Test” is recorded within the Orders Results app <= 2 years
before or during the measurement period.
Note: This CQM requires that a lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
4. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
The patient can be excluded from the denominator if they have a procedure of “Hysterectomy
with No Residual Cervix” performed and recorded in the Orders/Results App before or during
the measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 127 NQF 0043 - Pneumonia Vaccination Status for Older Adults
[CPE]
Percentage of patients 65 years of age and older who have ever received a pneumococcal
vaccine.
Initial Patient Population: Patients 65 years of age and older with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Patients who have ever received a pneumococcal vaccination
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient has one of the following entries in their record before or during the measurement
period:
•
The patient has a vaccination of “Pneumococcal” with a status of Complete recorded
within the Patient Immunizations PowerTab,
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–OR–
•
An entry in the Orders/Results app for a “Pneumococcal” procedure.
–OR–
•
An entry for “Pneumococcal” vaccine within the Diagnoses app with a status of Active
or Resolved recorded during the measurement period.
4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of
Payment codes; which are entered in the Patient Demographics screen.
This document provides general guidance from SRS to help clients understand and report on Clinical
Quality Measures. Clients are advised to refer to the specifications provided by Centers for Medicare
& Medicaid Services as the definitive source at eCQM Specifications for Eligible Professionals
Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 130 NQF 0034 - Colorectal Cancer Screening [CPE]
Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.
Initial Patient Population: Patients 50-75 years of age with a visit during the measurement
period
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients with a diagnosis or past history of total colectomy or
colorectal cancer
Numerator: Patients with one or more screenings for colorectal cancer. Appropriate
screenings are defined by any one of the following criteria below:
• Fecal occult blood test (FOBT) during the measurement period
• Flexible sigmoidoscopy during the measurement period or the four years prior to the
measurement period
• Colonoscopy during the measurement period or the nine years prior to the
measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. The patient has one of the following recorded in their chart:
•
A procedure of “Colonoscopy” recorded within the Orders/Results app with a status of
“Performed” during the measurement period or 9 years prior to the measurement period.
–OR–
•
A lab test result for “Fecal Occult Blood Test (FOBT)” recorded in the Orders/Results
app.
Note: This CQM requires that a lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
–OR–
•
A procedure of “Flexible Sigmoidoscopy” recorded within the Orders/Results app with a
status of “Performed” during the measurement period or 4 years prior to the
measurement period.
4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
The patient has one of the following recorded in their chart done during or before the
measurement period:
•
A diagnosis of “Malignant Neoplasm of Colon” recorded within the Diagnoses App with a
status of Resolved or Active or Inactive.
–OR–
•
A procedure of “Total Colectomy” recorded within the Orders/Results app with a status of
Performed; or a historical diagnosis of the same recorded in the Diagnoses App.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 131 / NQF 0055 - Diabetes: Eye Exam [CPE]
Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam
by an eye care professional during the measurement period or a negative retinal exam (no
evidence of retinopathy) in the 12 months prior to the measurement period
Initial Patient Population: Patients 18-75 years of age with diabetes with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Numerator: Patients with an eye screening for diabetic retinal disease. This includes
diabetics who had one of the following: A retinal or dilated eye exam by an eye care
professional in the measurement period or a negative retinal exam (no evidence of
retinopathy) by an eye care professional in the year prior to the measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of Diabetes in the Diagnosis app; add it if
necessary.
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4. Open the Vitals App and enter the following data points in the Retinal or Dilated Eye
Exam fields:
•
The Negative Finding checkbox should be checked <= 12 months before start of the
measurement period
–OR–
•
Either the Negative Finding or Positive Finding checkbox should be checked during
the measurement period
–AND–
•
The appropriate Procedure should be selected from the drop down list.
Note: Ensure that the start time and end time on the vitals app are recorded accurately;
while recording data within the vitals app the user must be in context of the encounter during
which the physical exam was performed.
5. Click on the Save & Close button on the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of
Payment codes; which are entered in the
Patient Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 132 NQF 0564 - Cataracts: Complications within 30 Days Following
Cataract Surgery Requiring Additional Surgical Procedures [PS]
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who
had cataract surgery and had any of a specified list of surgical procedures in the 30 days
following cataract surgery which would indicate the occurrence of any of the following major
complications: retained nuclear fragments, endophthalmitis, dislocated or wrong power IOL,
retinal detachment, or wound dehiscence.
Initial Patient Population: All patients aged 18 years and older who had cataract surgery
and no significant pre-operative ocular conditions impacting the surgical complication rate
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients with any one of a specified list of comorbid conditions
that impact the surgical complication rate
Numerator: Patients who had one or more specified operative procedures for any of the
following major complications within 30 days following cataract surgery: retained nuclear
fragments, endophthalmitis, dislocated or wrong power IOL, retinal detachment, or wound
dehiscence
Note: This is a reverse scored measure that means a lower numerator is better. Hence
providers should not be encouraged to meet the numerator of this measure.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. The patient should have a procedure for “Cataract Surgery” recorded within the
Orders/Results app during the measurement period
4. The patient should have one of the specified operative procedures for major complications
recorded within the Orders/Results app <= 30 days after cataract surgery.
5. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
The patient will be excluded from the denominator if they have appropriate diagnosis in their
chart related to ocular conditions recorded within the Diagnoses app before the start date/time
of the procedure of “Cataract Surgery”.
–OR–
The patient will be excluded from the denominator if they have prior “Pars Plana Vitrectomy”
procedure recorded within the Orders/Results app that ends before the start date/time of the
procedure of “Cataract Surgery”
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–OR–
Record an active medication included in the ‘Use of Systemic Sympathetic alpha-1a Antagonist
Medication for Treatment of Prostatic Hypertrophy’ data value set before the start date/time of
the procedure of “Cataract Surgery”
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 133 / NQF 0565 - Cataracts: 20/40 or Better Visual Acuity within 90
Days Following Cataract Surgery [CPE]
Percentage of patients aged 18 years and older with a diagnosis of uncomplicated cataract who
had cataract surgery and no significant ocular conditions impacting the visual outcome of
surgery and had best-corrected visual acuity of 20/40 or better (distance or near) achieved
within 90 days following the cataract surgery.
Initial Patient Population: All patients aged 18 years and older who had cataract surgery
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients with specified ocular conditions impacting the visual
outcome of surgery
Numerator: Patients who had best-corrected visual acuity of 20/40 or better (distance or
near) achieved within 90 days following cataract surgery
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: Subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of uncomplicated Cataract in the Diagnosis
app; add it if necessary.
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4. The patient should have a procedure for “Cataract Surgery” recorded within the
Orders/Results app.
Note: Surgeries that occur during January 1 – September 30th will be counted for this
measure.
5. The patient should have a visual acuity of 20/40 or better recorded using the Visual Acuity
app <= 90 days after the completion date/time of the procedure of “Cataract Surgery”.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
The patient will be excluded from the denominator if they have appropriate diagnosis in their
chart related to significant ocular conditions that impact the visual outcome of surgery recorded
within the Diagnoses app before the completion date/time of the procedure of “Cataract
Surgery”.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 134 / NQF 0062 - Diabetes: Urine Protein Screening [CPE]
The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening
test or evidence of nephropathy during the measurement period.
Initial Patient Population: Patients 18-75 years of age with diabetes with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Numerator: Patients with a screening for nephropathy or evidence of nephropathy during
the measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of Diabetes in the Diagnosis app; add it if
necessary.
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4. The patient has one of the following recorded in their chart:
a. An “ACE inhibitor or ARM” recorded in the Rx module with a status of Active before or
during the measurement period.
–OR–
b. An Active diagnosis recorded before or during the measurement period, from one of the
following:
•
•
•
•
“Hypertensive Chronic Kidney Disease”
“Glomerulonephritis and Nephrotic Syndrome”
“Diabetic Nephropathy”
“Proteinuria”
–OR–
c. A procedure with the status of Performed entered within the Orders/Results app during
the measurement period, from one of the following:
•
•
•
•
•
“Kidney Transplant”
“Vascular Access for Dialysis”
“Dialysis Services”
“Other Services Related to Dialysis”
“Dialysis Education
–OR–
d. An encounter of “ESRD Monthly Outpatient Services” with the status of “Performed”
entered within the Visit Type app during the measurement period.
–OR–
e. A lab result of “Microalbumin Test” entered within the Orders/Results app during the
measurement period.
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–OR–
f.
A lab result of “Macroalbumin Test (result: 'Positive Finding')” entered within the
Orders/Results app during the measurement period.
Note: This CQM requires that a lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the
appropriate code to accurately report this measure can be found in Appendix B and C of
the SRS v9 Orders and Results Manual (Article 937 in the SRS Knowledgebase).
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 135 NQF 0081 - Heart Failure (HF): Angiotensin-Converting Enzyme
(ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left
Ventricular Systolic Dysfunction (LVSD) [CPE]
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a
current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE
inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR
at each hospital discharge.
Initial Patient Population: All patients aged 18 years and older with a diagnosis of heart
failure
Denominator: Equals Initial Patient Population with a current or prior LVEF < 40%
Denominator Exclusions: None
Numerator: Patients who were prescribed ACE inhibitor or ARB therapy either within a 12
month period when seen in the outpatient setting or at hospital discharge
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: There must be 2 or more encounters with visit codes added during the measurement
period.
–AND–
The patient must be seen for the appropriate first occurrence of encounter during the
measurement period.
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3. The patient has an active diagnosis of “Heart failure” recorded within the Diagnoses app
before or during the first occurrence of the encounter
–AND–
4. The patient should have “Moderate or Severe LVSD” recorded within the Diagnoses app
before or during the first occurrence of the encounter
5. Within the Rx module document:
•
An order for an ACE Inhibitor during the first occurrence of encounter
–OR–
•
An active ACE Inhibitor or ARB prior to or during the first occurrence of encounter
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Denominator Exceptions:
Document reason for not prescribing ACE Inhibitor or ARB using the Rx Decline app during the
measurement period:
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1. Click on the “Decline” icon on the Rx History app
2. The Reason for Decline dialogue box appears; click on the Prescription tab.
3. The Date/Time fields default to the current date and time. Click in these fields to make
changes, if desired.
4. Search for the ACE Inhibitor or ARB drug; type in the search field and press the [Enter] key.
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5. A list of drugs appears in the Description column. Click on one of the drugs to select it.
(Note: You can select any dosage.)
6. A list of Reasons appears. Click on the appropriate reason to select it.
7. Click on the Save & Close button.
–OR–
Document one of the following active diagnoses within the Diagnosis app prior to or during the
first encounter:
•
•
•
•
•
Allergy to Ace inhibitor or ARB
Intolerance to Ace inhibitor or ARB
Pregnancy
Renal failure due to Ace inhibitor
Document an allergy/intolerance to Ace inhibitor or ARB within Rx module
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Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 138 NQF 0028 - Preventive Care and Screening: Tobacco Use:
Screening and Cessation Intervention [PPH]
Percentage of patients aged 18 years and older who were screened for tobacco use one or
more times within 24 months AND who received cessation counseling intervention if identified
as a tobacco user.
Initial Patient Population: All patients aged 18 years and older seen for at least two visits or
at least one preventive visit during the measurement period.
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Patients who were screened for tobacco use at least once within 24 months
AND who received tobacco cessation counseling intervention if identified as a tobacco user
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: In most cases, two or more encounters are required during the measurement period.
3. Record the patient’s current smoking status in the Smoking app. If a patient is a smoker
record one of the following within 24 months from the measurement end date:
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•
Tobacco cessation counseling documented within the Smoking app.
a. Click in the Post-screening plan time Start field to enter the time cessation counseling
began.
b. Click on the green plus icon for the desired Smoking and tobacco use cessation
counseling option in the Post-screening plan list. (Note: Hover your mouse over each
plan to view the full description.)
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c. The Post-screening plan End time is recorded and the Enter additional information
dialogue box simultaneously closes; the status is recorded with the post-screening plan
indicated. (Note: Hover your mouse over the icon to view the full description.)
–OR–
•
Tobacco use cessation drugs prescribed within the Rx module
4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exceptions:
The patient will be an exception on the denominator if one of the below is recorded in their
chart:
•
If screening was not performed, the medical reason or appropriate exceptions needs to be
captured within the Smoking App using the Not screened – medical reason button during
measurement period,
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–OR–
•
If the patient has an active diagnosis of “Limited Life Expectancy” grouping recorded
within the Diagnoses app before or during measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 139 NQF 0101 - Falls: Screening for Future Fall Risk [PS]
Percentage of patients 65 years of age and older who were screened for future fall risk during
the measurement period.
Initial Patient Population: Patients aged 65 years and older with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Patients who were screened for future fall risk at least once within the
measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should be assessed for Falls Screening and have the ‘Assessment for risk
of fall’ procedure recorded within the Orders/Results app.
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4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exception:
The patient should have a Medical Reason for not having a “Falls Screening” recorded within
the Orders/Results app:
1. Enter “Falls Screening” as a Completed order; and click on the Disposition field, under the
Orders section.
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2. The Completed Orders dialogue box appears; click on the Order Disposition down arrow
and select Not Performed, Medical Reason. Then click on the OK button.
3. The Disposition is changed.
4. Click on the Issue Orders button at the bottom of the Orders Entry screen.
–OR–
Patient should have a “Risk Category Assessment: Patient not ambulatory” recorded within the
Diagnosis app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015..
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2016 Clinical Quality Measure Cheat Sheet
CMS 142 NQF 0089 - Diabetic Retinopathy: Communication with the
Physician Managing Ongoing Diabetes Care [CPE]
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who
had a dilated macular or fundus exam performed with documented communication to the
physician who manages the ongoing care of the patient with diabetes mellitus regarding the
findings of the macular or fundus exam at least once within 12 months.
Initial Patient Population: All patients aged 18 years and older with a diagnosis of diabetic
retinopathy.
Denominator: Equals Initial Patient Population who had a dilated macular or fundus exam
performed
Denominator Exclusions: None
Numerator: Patients with documentation, at least once within 12 months, of the findings of
the dilated macular or fundus exam via communication to the physician who manages the
patient’s diabetic care
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
.
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3. The patient has an active diagnosis of “Diabetic Retinopathy” recorded within the
Diagnoses app before or during the first occurrence of the encounter.
4.
Record the following within the Vitals app:
a. Macular Exam - Check in the Performed checkbox
b. The Macular Exam dialogue box appears. Click on an option under Retinopathy
Severity to select it. Click on an option under Macular Edema to select it.
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c. Click on the buttons to the right to indicate the affected eye(s); the selection is added.
5. Click on the Select & Close button; the documented Macular Exam is indicated by the
green checkmark that appears to the right. There is also a Macular exam findings
hyperlink.
Note: if you click on the hyperlink, it clears your previous entry and allows you to re-enter
the information.
6. The provider must communicate the Macular Exam findings to the patient’s ongoing care
provider who manages his/her diabetes. To document this, click in the Communicated
Results checkbox once the communication is complete.
7. Record the Start Time and End Time on the Vitals app.
Note: Ensure the Start Time in the Vitals app is greater than the Start Time in the
Encounter Time app.
8. Click on the Save & Close button on the Vitals app.
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9. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
If the results were not communicated:
1. Click on the down arrow.
2. A dialogue box appears; click on a reason to select it.
3. Record the Start Time and End Time on the Vitals app.
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Note: Ensure the Start Time in the Vitals app is greater than the Start Time in the
Encounter Time app.
4. Click on the Save & Close button on the Vitals app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 143 / NQF 0086 - Primary Open-Angle Glaucoma (POAG): Optic
Nerve Evaluation [CPE]
Percentage of patients aged 18 years and older with a diagnosis of POAG who have an optic
nerve head evaluation during one or more office visits within 12 months
Initial Patient Population: All patients aged 18 years and older with a diagnosis of primary
open-angle glaucoma and an encounter during the measurement period.
Denominator: Equals Initial Patient Population
Numerator: Patients who have an optic nerve head evaluation during one or more office
visits within 12 months
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of primary open-angle glaucoma in the
Diagnosis App; add it if necessary.
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4. Open the Vitals app and enter the following data points:
a. Cup to Disc Ratio
i.
Click in the Performed checkbox
ii.
The Cup to Disc Ratio dialogue box appears, click on the buttons to select the
values; or type the values in the Click to add value manually box.
Click on the buttons
iii.
Or type in a value
Then click on the Add OU & Close or Add & Close buttons as appropriate. The
values display in the Vitals app.
Note: If you need to make changes click on the Cup to Disc Ratio values link; this will
clear the previous entries. Repeat the previous steps to enter the new values.
b. Optic Disc Exam
iv.
Click in the Performed checkbox
v.
The Optic Disc Exam Findings dialogue box appears; click on the down arrows to
select the values.
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vi.
Then click on the Add OU & Close or Add & Close buttons as appropriate. The
Vitals app indicates the findings were documented (green checkmark).
Note: If you need to make changes click on the Optic disc exam findings link; this will
clear the previous entries. Repeat the previous steps to enter the new values.
If you did not enter the Cup to Disc Ratio and/or the Optic Disc Exam information in the
Vitals app, click on the Reason for decline button. The Reason for Decline dialogue box
appears.
Click on the down arrow next to the Cup to Disc Ratio or the Optic Disc Exam field and
click on a reason from the list to select it.
Repeat for the second data field if neither the Cup to Disc Ratio nor the Optic Disc Exam
information was documented.
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Click on the OK button.
5. Click on the Save & Close button at the bottom of the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 144 NQF 0083 - Heart Failure (HF): Beta-Blocker Therapy for Left
Ventricular Systolic Dysfunction (LVSD) [CPE]
Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a
current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker
therapy either within a 12 month period when seen in the outpatient setting OR at each hospital
discharge.
Initial Patient Population: All patients aged 18 years and older with a diagnosis of heart
failure and two or more encounters during the measurement period.
Denominator: Equals Initial Patient Population with a current or prior LVEF < 40%
Denominator Exclusions: None
Numerator: Patients who were prescribed beta-blocker therapy either within a 12 month
period when seen in the outpatient setting or at hospital discharge
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: The patient must be seen for two or more encounters during the measurement period.
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The patient has an active diagnosis of “Heart failure” recorded within the Diagnoses app
before or during the first occurrence of the encounter
–AND–
The patient should have Moderate or Severe LVSD recorded within the Diagnoses app
before or during the first occurrence of the encounter
3. Within the Rx module document:
•
An order for beta blocker therapy during the first occurrence of encounter
–OR–
•
An active beta blocker prior to or during the first occurrence of encounter
4. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exceptions (meet one of the following):
Within the Vitals app the pulse is recorded twice or more during the first occurrence of the
encounter and the 2 most recent pulse readings are both <=50 bpm.
–OR–
Document the reason for not prescribing beta blocker using the Rx Decline app during the
current encounter:
1. Click on the “Decline” icon on the Rx History app
2. The Reason for Decline dialogue box appears; click on the Prescription tab.
3. The Date/Time fields default to the current date and time. Click in these fields to make
changes, if desired.
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4. Search for the beta blocker; type in the search field and press the [Enter] key.
5. A list of drugs appears in the Description column. Click on one of the drugs to select it.
(Note: You can select any dosage.)
6. A list of Reasons appears. Click on the appropriate reason to select it.
7. Click on the Save & Close button.
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–OR–
Document one of the following active diagnoses within the Diagnoses app prior to or during the
first encounter:
•
•
•
•
•
•
•
Arrhythmia
Hypotension
Asthma
Allergy to Beta Blocker
Intolerance to Beta Blocker
Bradycardia
Atrioventricular Block
–OR–
Document an allergy/intolerance to beta blocker therapy within Rx module
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 145 NQF 0070 - Coronary Artery Disease (CAD): Beta-Blocker
Therapy—Prior Myocardial Infarction (MI) or Left Ventricular Systolic
Dysfunction (LVEF <40%) [CPE]
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease
seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who
were prescribed beta-blocker therapy.
Initial Patient Population: All patients aged 18 years and older with a diagnosis of coronary
artery disease seen within a 12 month period who had two or more encounters during the
measurement period.
Denominator: Equals Initial Patient Population who also have prior MI or a current or prior
LVEF <40%
Denominator 1: Patients with left ventricular systolic dysfunction (LVEF <40%)
Denominator 2: Patients with a prior (resolved) myocardial infarction
Denominator Exclusions: None
Numerator: Patients who were prescribed beta-blocker therapy
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: The patient must be seen for two or more encounters during the measurement period
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.
3.
An active diagnosis of “Coronary Artery Disease no MI” is recorded in the Diagnoses app.
–OR–
“Cardiac Surgery” performed recorded in Orders/Results app before or during the
occurrence of the first encounter.
4. The patient has an active diagnosis of “Moderate or Severe LVSD” recorded within the
Diagnoses app either prior to or during the current encounter
–OR–
The patient has a resolved diagnosis of “Myocardial Infarction” recorded within the
Diagnoses app either prior to or during the current encounter.
5. A medication order for beta blocker therapy for LVSD is recorded within the Rx module
during the first encounter.
–OR–
An active Beta blocker therapy for LVSD is recorded within the Rx module prior to or during
the first encounter
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6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking app.
Denominator Exceptions:
The patient’s heart rate is measured 2 or more times during the current encounter and the two
most recent heart rate readings are both < 50 bpm.
–OR–
Document the reason for not prescribing beta blocker using the Rx Decline app during the
current encounter:
1. Click on the “Decline” icon on the Rx History app
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2. The Reason for Decline dialogue box appears; click on the Prescription tab.
3. The Date/Time fields default to the current date and time. Click in these fields to make
changes, if desired.
4. Search for the beta blocker; type in the search field and press the [Enter] key.
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5. A list of drugs appears in the Description column. Click on one of the drugs to select it.
(Note: You can select any dosage.)
6. A list of Reasons appears. Click on the appropriate reason to select it.
7. Click on the Save & Close button.
–OR–
Document one of the following active diagnoses within the Diagnoses app prior to or during the
first encounter:
•
•
•
•
Arrhythmia
Hypotension
Asthma
Allergy to Beta Blocker
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•
•
•
Intolerance to Beta Blocker
Bradycardia
Atrioventricular Block
–OR–
Document an allergy/intolerance to beta blocker therapy within Rx module.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015..
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2016 Clinical Quality Measure Cheat Sheet
CMS 147 NQF 0041 - Preventive Care and Screening: Influenza
Immunization [PPH]
Percentage of patients aged 6 months and older seen for a visit between October 1 and March
31 who received an influenza immunization OR who reported previous receipt of an influenza
immunization.
Initial Patient Population: All patients aged 6 months and older
Denominator: Equals Initial Patient Population and seen for a visit between October 1 and
March 31
Denominator Exclusions: None
Numerator: Patients who received an influenza immunization OR who reported previous
receipt of an influenza immunization
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
Note: The patient should have more than 2 encounters recorded in the Visit Type app.
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3. The patient has a vaccination of “Influenza” with a status of Complete recorded within the
Patient Immunizations PowerTab,
-OR–
The patient has an active diagnosis of “Received influenza vaccination…” recorded
within the Diagnoses App,
Note: Diagnosis must be recorded during 10/1 – 12/31 of the previous year or 1/1 – 3/31 of current
year to count for current year reporting.
–OR–
The patient has a procedure for “Influenza Vaccination” recorded within the Orders/Results
app with the status of Completed.
4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exceptions:
1. The completion status for not administering the patient with the Influenza vaccine is
recorded within the Patient Immunization PowerTab.
-OR2. The patient has an Active diagnosis of allergy to eggs or allergy to influenza vaccine or
intolerance to influenza vaccine recorded within the Diagnoses App.
-OR3. The patient has the intolerance recorded within the Patient Immunization PowerTab by
selecting a Not Administered – Contraindicated reason.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 148 / NQF 0060 - Hemoglobin A1c Test for Pediatric Patients [CPE]
Percentage of patients 5-17 years of age with diabetes with an HbA1c test during the
measurement period.
Initial Patient Population: Patients 5 to 17 years of age with a diagnosis of diabetes and a
face-to-face visit for diabetes care between the physician and the patient that predates the
most recent visit by at least 12 months
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Patients with documentation of date and result for a HbA1c test during the
measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of Diabetes in the Diagnosis app; add it if
necessary during the current encounter.
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4. A lab order result for “HbA1c” is recorded in the Orders/Results app during the
measurement period.
Note: This CQM requires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 153 NQF 0033 - Chlamydia Screening for Women [PPH]
Percentage of women 16-24 years of age who were identified as sexually active and who had at
least one test for chlamydia during the measurement period.
Initial Patient Population: Women 16 to 24 years of age who are sexually active and who
had a visit in the measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: Women who received a pregnancy test solely as a safety
precaution before ordering an x-ray or specified medications
Numerator: Women with at least one chlamydia test during the measurement period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient has an active diagnosis associated with one of the Data Value Set categories listed
below recorded within the Diagnoses app before or during the measurement period:
•
•
•
•
“Other Female Reproductive Conditions”
“Genital Herpes”
“Gonococcal Infections and Venereal Diseases”
“Contraceptive Medications”
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•
•
•
•
•
“Inflammatory Diseases of Female Reproductive Organs”
“Chlamydia”
“HIV”
“Syphilis”
“Complications of Pregnancy, Childbirth and the Puerperium”
–OR–
The patient has an active lab order associated with one of the Data Value Set categories listed
below recorded within the Orders/Results app during the measurement period:
•
•
•
•
“Pregnancy”
“Pap Test”
“Lab Tests during Pregnancy”
“Lab Tests for Sexually Transmitted Infections”
Note: This CQM requires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
–OR–
The patient has a procedure associated with one of Data Value Set categories listed below
with a status of Performed recorded within the Orders/Results app during the
measurement period:
•
•
•
“Delivery Live Births”
“Procedures during Pregnancy”
“Procedures Involving Contraceptive Devices”
–OR–
The patient has a radiology order associated with the “Diagnostic Studies During Pregnancy”
Data Value Sets category recorded within the Orders/Results app during the measurement
period:
–OR–
The patient has an active medication order for “Contraceptive Medications” recorded within
the Rx module.
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4. A lab order result for “Chlamydia” recorded within the Orders/Results app during the
measurement period.
Note: This CQM measure requires that the lab order being placed is associated with an
appropriate LOINC code from the CMS provided value set. Instructions on how to map the
appropriate code to accurately report this measure can be found in Appendix B and C of the
SRS v9 Orders and Results Manual (Article 937 in the SRS Knowledgebase).
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Denominator Exclusions:
An active lab order of “Pregnancy” recorded within the Orders/Results app during the
measurement period
–AND–
•
A medication order for “Isotretinoin” recorded within the Rx module <= 7 days after the
occurrence of the lab order
–OR–
•
A radiology order for “X-Ray Study (all inclusive)” recorded within the Orders/Results
app <= 7 days after the occurrence of the lab order
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
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This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 155 / NQF 0024 - Weight Assessment and Counseling for Nutrition
and Physical Activity for Children and Adolescents [PPH]
Percentage of patients 3-16 years of age who had an outpatient visit with a Primary Care
Physician (PCP) or Obstetrician/ Gynecologist (OB/GYN) and who had evidence of the following
during the measurement period. Three rates are reported.
• Percentage of patients with height, weight, and body mass index (BMI) percentile
documentation
• Percentage of patients with counseling for nutrition
• Percentage of patients with counseling for physical activity
Initial Patient Population: Patients 3-16 years of age with at least one outpatient visit with
a primary care physician (PCP) or an obstetrician/gynecologist (OB/GYN) during the
measurement period
Denominator: Equals initial patient population
Denominator Exclusions: Patients who have a diagnosis of pregnancy during the
measurement period
Numerator:
Numerator 1: Patients who had a height, weight and body mass index (BMI) percentile
recorded during the measurement period
Numerator 2: Patients who had counseling for nutrition during the measurement period
Numerator 3: Patients who had counseling for physical activity during the measurement
period
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. Open the Vitals app and enter the following data points (note, there are three numerators
for this measure):
a. Numerator 1: Record the patient’s Height and Weight.
b. Numerator 2: Click on the Counseling link on the BMI section.
The Counseling dialogue box appears. Select an option from the Counseling for
Nutrition list.
–AND–
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Numerator 3: Select an option from the Counseling for Physical Activity list.
4. Click on the Select & Close button on the Counseling dialogue box. The Counseling link
displays with a green checkmark in the icon indicating counseling has been provided to the
patient.
Note: The most recent vital signs display on the Dashboard. An indication of whether or not the
BMI has been recorded can be found on the iDash.
• If the BMI has been recorded but no Counseling has been selected, users will see this
icon:

If the BMI has been recorded and the Counseling has been selected, users will see this
icon:
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In the Vitals history display; you can hover your mouse over the
appears with the Counseling options selections.
icon, and a pop-up
Click on the x button to close the Vitals history.
5. Click on the Save & Close button on the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
The patient has an active diagnosis of “Pregnancy” recorded in the Diagnoses app before or
during the measurement period.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 156 NQF 0022 - Use of High-Risk Medications in the Elderly [PS]
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two
rates are reported.
a. Percentage of patients who were ordered at least one high-risk medication.
b. Percentage of patients who were ordered at least two different high-risk medications.
Initial Patient Population: Patients 66 years and older who had a visit during the
measurement period
Denominator: Equals initial patient population
Denominator Exclusions: None
Numerator:
Numerator 1: Patients with an order for at least one high-risk medication during the
measurement period.
Numerator 2: Patients with an order for at least two different high-risk medications during the
measurement period.
Note: This is a reverse scored measure that means a lower numerator is better. Hence
providers should not be encouraged to meet the numerator of this measure.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. One (1) or more medication orders for high risk medication for elderly are prescribed within
the Rx module.
4. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 158 NQF 0608 - Pregnant women that had HBsAg testing [CPE]
This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their
pregnancy.
Initial Patient Population: All female patients aged 12 and older who had a full term
delivery during the measurement period.
Denominator: Equals Initial Patient Population.
Denominator Exclusions: None
Numerator: Patients who were tested for Hepatitis B surface antigen (HBsAg) during
pregnancy within 280 days prior to delivery.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient has the delivery procedure recorded within the Orders/Results app during the
measurement period.
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–AND–
4. The patient has an active diagnosis of ‘live birth or delivery’ recorded within the
Diagnoses app and does not END before the start of the delivery procedure.
5. Patient has a HBsAg lab test performed and recorded within the Orders/Results app <=280
days prior to the delivery procedure.
Note: This CQM requires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
6. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Denominator Exceptions:
Patient has an active/inactive diagnosis of Hepatitis B recorded within the diagnosis app <=365
years prior to the delivery procedure.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
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This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 163 NQF 0064 - Diabetes: Low Density Lipoprotein (LDL)
Management [CPE]
Percentage of patients 18–75 years of age with diabetes whose LDL-C was adequately
controlled (<100 mg/dL) during the measurement period.
Initial Patient Population: Patients 18-75 years of age with diabetes with a visit during the
measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Patients whose most recent LDL-C level performed during the measurement
period is <100 mg/dL
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of Diabetes in the Diagnosis app; add it if
necessary.
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4. The most recent lab test result for “LDL-C Laboratory Test” has a result of “<100 mg/dL”
recorded within the Orders/Results app during the measurement period.
Note: This CQM requires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2014 Clinical Quality Measure Cheat Sheet
CMS 165 / NQF 0018 – Controlling High Blood Pressure [CPE]
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose
blood pressure was adequately controlled (<140/90mmHg) during the measurement period.
Initial Patient Population: Patients 18-85 years of age who had a diagnosis of essential
hypertension within the first six months of the measurement period or any time prior to the
measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: Patients with evidence of end stage renal disease (ESRD),
dialysis or renal transplant before or during the measurement period. Also exclude patients
with a diagnosis of pregnancy during the measurement period.
Numerator: Patients whose most recent blood pressure is adequately controlled (systolic
blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the
measurement period.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
3. The patient should have an active diagnosis of Essential Hypertension in the Diagnosis
app; add it if necessary. (Note: it should be added within the first six months of the
measurement period or any time prior to the measurement period.)
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4. Open the Vitals app and enter the blood pressure.
Note: Ensure that the Start Time and End Time on the vitals app are recorded accurately.
5. Click on the Save & Close button at the bottom of the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 166 / NQF 0052 - Use of Imaging Studies for Low Back Pain [EUHR]
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have
an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.
Initial Patient Population: Patients 18-50 years of age with a diagnosis of low back pain
during an outpatient or emergency department visit
Denominator: Equals Initial Patient Population
Denominator Exclusions: Exclude patients with a diagnosis of cancer any time in their
history or patients with a diagnosis of recent trauma, IV drug abuse, or neurologic
impairment during the 12-month period prior to the outpatient or emergency department
visit.
Exclude patients with a diagnosis of low back pain within the 180 days prior to the outpatient
or emergency department visit.
Numerator: Patients with an imaging study conducted on the date of the outpatient or
emergency department visit or in the 28 days following the outpatient or emergency
department visit
Note: This is a reverse-scored measure (a lower numerator is better). Hence providers
should not be encouraged to meet the numerator of this measure.
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. The patient should have an active diagnosis of “Low back pain” recorded within the
Diagnoses app during the measurement period.
Note: The diagnosis should be documented during the encounter that happens <= 337 days
after the start of the measurement period.
4. The patient should not have a diagnostic study for the following tests recorded within the
Orders/Results app with the disposition of “Performed” <= 28 days after the diagnosis date
of “Low back pain”:
•
•
•
X-ray of lower spine
MRI of lower spine
CT scan of lower spine
5. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
The patient has an active/resolved/inactive diagnosis of “Cancer” recorded in the Diagnoses
app before or during the measurement period.
–OR–
The patient has an active diagnosis of “Trauma” or “IV Drug Abuse”or “Neurologic impairment”
recorded in the Diagnoses app <= 365 days before or during the measurement period.
–OR–
The patient has another occurrence of active diagnosis of “Low back pain” recorded in the
Diagnoses app <= 180 days before the diagnosis date of the initial occurrence of “Low back
pain”.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 167 / NQF 0088 - Diabetic Retinopathy: Documentation of Presence
or Absence of Macular Edema and Level of Severity of Retinopathy
[CPE]
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who
had a dilated macular or fundus exam performed which included documentation of the level of
severity of retinopathy and the presence or absence of macular edema during one or more
office visits within 12 months
Initial Patient Population: All patients aged 18 years and older with a diagnosis of diabetic
retinopathy
Denominator: Equals Initial Patient Population
Denominator Exclusions: None
Numerator: Patients who had a dilated macular or fundus exam performed which included
documentation of the level of severity of retinopathy AND the presence or absence of
macular edema during one or more office visits within 12 months
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. The patient should have an active diagnosis of Diabetic Retinopathy in the Diagnosis app;
add it if necessary.
4. Open the Vitals app and enter the following data points:
a. In the Macular Exam section, click in the Performed checkbox .
b. The Macular Exam dialogue box displays. Select the appropriate Retinopathy Severity
and Macular Edema.
c. Then select OU, OD or OS.
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d. Your selection displays in the bottom panel. Click on the Select & Close button.
Note: Ensure that the start time and end time on the Vitals app are recorded accurately.
5. Click on the Save & Close button on the Vitals app.
6. Enter the Encounter Close Time using the Encounter Time app or the Patient Tracking
app.
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Denominator Exclusions:
If the patient declines to have the exam, click on the Reason for Decline button in the Vitals
app. The Reason for Decline dialogue box appears. Click on the down arrow for Macular
Exam and click on a reason to select it.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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2016 Clinical Quality Measure Cheat Sheet
CMS 182 NQF 0075 - Ischemic Vascular Disease (IVD): Complete Lipid
Panel and LDL Control [CPE]
Percentage of patients 18 years of age and older who were discharged alive for acute
myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary
interventions (PCI) in the 12 months prior to the measurement period, or who had an active
diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had a
complete lipid profile performed during the measurement period and whose LDL-C was
adequately controlled (< 100 mg/dL).
Initial Patient Population: Patients 18 years of age and older with a visit during the
measurement period, and an active diagnosis of ischemic vascular disease (IVD) during the
measurement period, or who were discharged alive for acute myocardial infarction (AMI),
coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12
months prior to the measurement period
Denominator: Equals Initial Patient Population
Denominator Exclusions: Not Applicable
Numerator:
Numerator 1: Patients with a complete lipid profile performed during the measurement
period
Numerator 2: Patients whose most recent LDL-C level performed during the measurement
period is <100 mg/dL
To document this measure:
1. Enter the Encounter Start Time using the Encounter Time app or the Patient Tracking
app.
Note: ALL subsequent data entry must be done before the Encounter Close!
2. Enter the appropriate E&M code in the Visit Type app.
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3. The patient has one of the following recorded in their chart:
•
An active diagnosis of “Acute Myocardial Infarction” <= 12 months before the start of
measurement period recorded within the Diagnoses app.
–OR–
•
An active diagnosis of “Ischemic Vascular Disease” before or during the measurement
period recorded within the Diagnoses app.
–OR–
•
A procedure of either “Percutaneous Coronary Intervention” or “Coronary Artery Bypass
Graft” with the status of “Performed” recorded in the Orders/Results app within the past
12 months of the measurement period.
4. The patient has one of the following recorded in their chart:
Numerator 1:
•
A lab test result for “Complete Lipid Panel” recorded within the Orders/Results app
during the measurement period
–OR–
•
A lab test result for “Total Cholesterol” and “HDL-C” and “LDL-C” and “Triglycerides”
recorded in the Orders/Results app during the measurement period.
Numerator 2:
•
The most recent lab test result for “LDL-C” is recorded with the result of < 100 mg/dL
within the Orders/Results app during the measurement period.
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Note: This CQM requires that the lab order being placed is associated with an appropriate
LOINC code from the CMS provided value set. Instructions on how to map the appropriate
code to accurately report this measure can be found in Appendix B and C of the SRS v9
Orders and Results Manual (Article 937 in the SRS Knowledgebase).
5. Enter the Encounter Close time using the Encounter Time app or the Patient Tracking
app.
Note: CQM reporting requires Source of Payment codes; which are entered in the Patient
Demographics screen.
This document provides general guidance from SRS to help clients understand and report on
Clinical Quality Measures. Clients are advised to refer to the specifications provided by Centers
for Medicare & Medicaid Services as the definitive source at eCQM Specifications for Eligible
Professionals Update June 2015.
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