Clinical Quality Measures - Meaningful Use |
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Alternate Core Clinical Measures |
Title |
Description |
Proceed in Detail
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Adult Weight Screening and Follow-Up |
Percentage of patients aged 18 years and older with a calculated BMI in the past
six months or during the current visit documented in the medical record AND if the
most recent BMI is outside parameters, a follow-up plan is documented. (Normal Parameters:
(a)age 18-64 BMI >=18.5 or <25; (b) age 65 and older BMI >=22 or <30.) |
(a) Numerator :
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The patient’s age should be between 18 and 64. The patient must also
have BMI in Vital signs chart. BMI must be recorded in the past 6 months to the encounter. Normal BMI - (BMI >= 18.5 or <25) and Abnormal BMI (BMI >= 25 or <18.5). If Patient has an Abnormal BMI then its latest encounter should contain one of the CPT Codes (G8417 or G8418 or S9470) OR select Counseling for Nutrition & physical activity in Measurement therapy. (In Followup tab)
[ :CPT Group name - BMI ]
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Denominator:
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No of Patients that were between the ages of 18 and 64. The patient
must have one encounter within the period
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(b)Numerator : |
The patient’s age should be 65 and older. The patient must also have BMI in Vital signs chart. BMI must be recorded in the past 6 months to the encounter. Normal BMI (BMI >= 22 or <30) and Abnormal BMI (BMI >= 30 or <22). If patient has an Abnormal BMI then its latest encounter should contain one of the CPT Codes (G8417 or G8418 or S9470) OR select Counseling for Nutrition & physical activity in Measurement therapy. (In Followup tab)
[ :: CPT Group name - BMI ]
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Denominator: |
No of Patients that were at least 65 and older. Patient must have one encounter within the period.
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Hypertension: Blood Pressure Measurement |
Percentage of patient visits for patients aged 18 years and older with a diagnosis
of hypertension who have been seen for at least 2 office visits, with blood pressure
(BP) recorded. |
Numerator: |
The number of patients in the denominator that have at least once BP recorded. |
Denominator: |
No of Patients that were ages at least 18 years old or older. Patient must have 2 encounters within the period and should have one of the ICD Codes: (401.0, 401.1, 401.9, 402.00, 402.01, 402.10, 402.11, 402.90, 402.91, 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01, 404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, and 404.93). |
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Preventive Care and Screening Measure Pair: a.Tobacco Use Assessment
b. Tobacco Cessation Intervention |
Percentage of patients aged 18 years and older who have been seen for at least 2
office visits who were queried about tobacco use one or more times within 24 months
b. Percentage of patients aged 18 years and older identified as tobacco users within
the past 24 months and have been seen for at least 2 office visits, who received
cessation intervention. |
a. Tobacco Use Assessment. |
b. Tobacco Cessation Intervention |
(a)Numerator: |
The number of patient’s in the denominator are of tobacco users and who have accomplished by having Smoking Status OR documentation of Smoking in one of the CPT Codes (1000F, 1034F, G8455, 1035F, G8456, 1036F, G8457)
[ :: CPT Group name – Smoking Documentation ]
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Denominator: |
The number of Patient’s must be at least 18 years old or older and must have at least 2 encounters within the period. |
(b)Numerator: |
The number of patient’s in the denominator were of tobacco users have documentation of Smoking cessation intervention either in one of the CPT Codes (4000F or 4001F.) OR selecting the “Smoking Cessation Intervention” in management therapy. (In Followup Tab)
[ :: CPT Group name – Smoking Cessation ]
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Denominator: |
The number of patient’s must be at least 18 years old or older and must have at least 2 encounters within the period and has being a tobacco user: Those were accomplished by the presence of Smoking status OR ICD code 305.1 or 305.10 OR CPT 1034F or 1035F.
[ :: CPT Group name – Smoking Documentation ]
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Alternate Core Clinical Measures |
Title |
Description |
Proceed in Detail |
Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old |
Percentage of patients aged 50 years and older who received an influenza immunization
during the flu season (September through February). |
Numerator: |
The number of patients in the denominator that have influenza vaccine 111 (influenza virus vaccine, live, attenuated, fo) or 140 (Influenza, seasonal, injectable, preservative) and the documentations of CPTs (90656, 90658, 90660, G0008, G8482, 4037F).
[ :: CPT Group name – Influenza Vaccine ]
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Denominator: |
The number of patient’s that were 50 years old or older and have at least one encounter within the period of September to February of next year. |
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Weight Assessment and Counseling for Children and Adolescents |
Percentage of patients 2 -17 years of age who had an outpatient visit with a Primary
Care Physician (PCP) or OB/GYN and who had evidence of BMI percentile documentation,
counseling for nutrition and counseling for physical activity during the measurement
year. |
Numerator: |
The number of patients in the denominator that have BMI reading in Vital signs and for the documentations of counseling use either weight counseling (CPT S9451) and nutrition counseling (CPT G0270, GG0271, S9449, S9452, S9470, 97802, 97803, or 97804) OR selecting Nutrition and physical activity in measurement therapy.
[ :: CPT Group name – Weight Counseling and Nutrition Counseling ]
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Denominator:
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The number of patient’s that were between 2 - 17 years and have at least one encounter within the period. |
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Childhood Immunization Status |
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); two H
influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal
conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza
(flu) vaccines by their second birthday. The measure calculates a rate for each
vaccine and nine separate combination rates. |
(a)Numerator1: |
The number of patients in the denominator that have
four DTaP;
three polio (IPV),
one (MMR);
two H influenza type B (HiB);
three hepatitis B (Hep B);
one chicken pox (VZV);
four pneumococcal conjugate (PCV);
two hepatitis A (Hep A);
two or three rotavirus (RV);
two influenza (flu) vaccines.
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(b)Numerator2: |
The number of patients in the denominator that have at least four DTaP. |
(c)Numerator3: |
The number of patients in the denominator that have at least three IPV. |
(d)Numerator4: |
The number of patients in the denominator that have at least one MMR. |
(e)Numerator5: |
The number of patients in the denominator that have at least two HiB. |
(f)Numerator6: |
The number of patients in the denominator that have at least three Hep B. |
(g)Numerator7: |
The number of patients in the denominator that have at least one Pox. |
(h)Numerator8: |
The number of patients in the denominator that have at least four Pneumococcal conjugate. |
(i)Numerator9: |
The number of patients in the denominator that have at least two Hep A. |
(j)Numerator10: |
The number of patients in the denominator that have at least two rotavirus. |
(k)Numerator11: |
The number of patients in the denominator that have at least two influenza. |
Denominator: |
The number of patients that were below 2 years and have at least one encounter within the period. |
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Optional Clinical Measures |
Title |
Description |
Proceed in Detail |
Smoking and Tobacco Use Cessation, Medical assistance: a. Advising Smokers and Tobacco
Users to Quit, b. Discussing Smoking and Tobacco Use Cessation Medications, c. Discussing
Smoking and Tobacco Use Cessation Strategies |
Percentage of patients 18 years of age and older who were current smokers or tobacco
users, who were seen by a practitioner during the measurement year and who received
advice to quit smoking or tobacco use or whose practitioner recommended or discussed
smoking or tobacco use cessation medications, methods or strategies. |
a. Advising Smokers and Tobacco Users to Quit. |
b. Discussing Smoking and Tobacco Use Cessation Medications. |
c. Discussing Smoking and Tobacco Use Cessation Strategies. |
Numerator:
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The number of patient’s in the denominator that have one of the CPT Codes (G8402, S9075, S4995, G0376, S9453, G0375, G9016, 99406 or 99407) OR selecting “Smoking Cessation Intervention” in Management Therapy. (In Followup Tab)
[ :: CPT Group name – Smoking Counseling ]
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Denominator: |
The number of patient’s that were 18 years old or older and have at least one encounter within the period and has one of the Diagnosis of (305.1 or 305.10.10 OR has one of the CPTs 1034F or 1035F. OR Tobacco user.
[ :: CPT Group name – Smoking Documentation ]
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Diabetes: Blood Pressure Management |
Percentage of patients 18 - 75 years of age with diabetes (type 1 or type 2) who
had blood pressure <140/90 mmHg. |
Numerator: |
The number of patients in the denominator whose last BP was < 140/90 |
Denominator: |
The number of patient’s that were between the ages of 18 and 75 and have at least one encounter within the period and has Diagnosis of ICD Codes are recorded.
Acceptable ICD codes: 250, 250.0, 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.4, 250.40, 250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.7, 250.70, 250.71, 250.72, 250.73, 250.8, 250.80, 250.81, 250.82, 250.83, 250.9, 250.90, 250.91, 250.92, 250.93, 357.2, 362.0, 362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.0, 648.00, 648.01, 648.02, 648.03, 648.04
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Breast Cancer Screening |
Percentage of women 40-69 years of age who had a mammogram to screen for breast
cancer. |
Numerator: |
The patients in the denominator who had mammogram at least once in the period OR CPTs need to be present: 77055, 77056, 77057, G0202, G0204, G0206, 3014F, 77052.
[ :: CPT Group name – Mammogram ]
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Denominator: |
The patients must be Female aged 40 - 69 and have at least one encounter within the period.
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