CMS Web Interface Weekly Support Call: Session 6
01
March

By Adem Lewis / in , , , , , , , , , , , , , , , , , /


…everybody, and thank you for joining today’s
CMS Web Interface Support Call. During today’s webinar, CMS will provide an
overview of 2019 CMS Web Interface Quality Reporting for MIPS Groups and ACOs. And after the webinar, CMS will take as many
questions as time allows. So, now I’ll turn it over to Sandra Adams
Slaughter from CMS to begin. Thank you, Kayte. Welcome, everyone, and thank you for joining
us today. I’m Sandra Adams Slaughter from CMS. Joining me on the call today are CMS subject
matter experts and contractors, who will share helpful information on CMS Web Interface quality
reporting and answer your questions during the question and answer session after today’s
presentation. Today’s call will only focus on CMS Web Interface
Quality Reporting. You can contact the Quality Payment Program
Service Center with any of your questions regarding Cost, Promoting Interoperability,
Improvement Activities, MIPS, or quality reporting in general. Next slide, please. This is a disclaimer slide about this presentation
today. Information in this presentation was correct
at the time it is published. But I urge you to use the source documents
and links that are provided throughout the presentation, and please stay tuned for any
communication from the Quality Payment Program, Medicare Shared Savings Program, ACO, or Next
Generation ACO Model regarding updated information. Next slide, please. So, the recording slides and transcript for
the February 5th call are now available on the Quality Payment Program Library web page. Next slide, please. So, here’s some CMS Web Interface key dates. The submission period for the CMS Web Interface
aligns with other submission types for 2019. The Web Interface opened on January 2nd and
will be closing at 8:00 p.m. Eastern Daylight Time on March 31, 2020. Your submission will automatically be accepted
at submission close. And as a reminder, the CMS Web Interface is
accessible using the sign-in link on the Quality Payment Program website, and you can see it
circled on the slide. Next slide, please. And here’s some additional announcements about
upcoming CMS Web Interface Support Calls. Today is part of a series of Web Interface
support calls held weekly throughout the data submission period. The next support call will be held next Wednesday,
February 26th, from 1:00 to 2:00 p.m. Eastern Standard Time. Topics will include FAQs for MH-1 and PREV-13,
followed by a question and answer period, and additional topics may be added prior to
next week’s support call. Next slide, please. Here’s a reminder that Other CMS Approved
Reason skip requests must be submitted through the CMS Web Interface. This is a way to skip patients attributed
to a measure during Denominator Confirmation. The CMS Approved Reason is reserved for circumstances
that are unique, unusual, and not covered by any of the denominator exclusions or denominator
exceptions identified in the measure specifications. Patients for whom a CMS Approved Reason is
selected will be skipped, and another patient must be reported in their place for the measure,
if available. Next slide, please. This is a reminder that the 2019 CMS Web Interface
API, Application Programming Interface, is available all year for testing in the Developer
Preview Environment. You can review the resources listed on this
slide for more information. Next slide, please. And now I will pass off the presentation to
Angela Stevenson, and she will discuss some frequently asked measure questions. Thanks, Sandra. Hi. This is Angie with the PIMMS measures team. Our first question is regarding the DM-2 measure:
“Will an HbA1c from a hospital encounter qualify for measure DM-2?” And, yes, it will. As identified on page 5 of the posted measure
specification, you should use the most recent HbA1c level that was performed during the
measurement period. The next question is on PREV-5: “If the
patient has a history of a right breast mastectomy and a unilateral left mammogram during the
measurement period, would this patient be excluded from the denominator, satisfy the
measure, or not satisfy the measure?” And mammography screening is defined as a
bilateral screening — both breasts — of all existing breast tissue. If there is medical-record documentation,
the patient had a unilateral mastectomy of the right breast, as in your example, then
a mammogram of the left breast during the measurement period, or the 15 months prior
to the measurement period, would meet the intent of the measure. There must be medical record documentation
that supports the information submitted. Next question is for PREV-6: “Can claims
data be used to confirm a patient had a colonoscopy at an outside organization?” Claims data can be used to aid you in finding
the quality action, but supporting medical-record documentation is required to substantiate
what is submitted. When submitting data through the CMS Web Interface,
the expectation is that medical-record documentation is available that supports the action submitted. Next slide, please. Next question is on PREV-7: “Are flu shots
that have been confirmed via claims eligible to meet the documentation requirement?” You are not required to provide medical-record
documentation for the prepopulated influenza immunization data that’s included in your
sample. However, if influenza immunization data is
not prepopulated, then you must have medical-record documentation to support that the immunization
was administered in accordance with the measure specifications. And the last question is on PREV-10: “Since
tobacco screening and cessation intervention, if positive for tobacco use, do not need to
be completed on the same encounter or need to be completed by the same provider or clinician,
is it still true that only the most recent screening should be used to satisfy the measure?” The answer is yes. If a patient has multiple tobacco use screenings
during the 24-month period, use the most recent tobacco use status. If the patient was determined to be a tobacco
user at that most recent screening, then there must be documentation that tobacco- use cessation
occurred during the 24-month period, which is January 1, 2018, through December 31, 2019,
for the performance year 2019, to meet the intent of the measure. Thank you very much. And I will return it back to Sandra Adams
Slaughter with CMS. Thank you, Angie. And now we will talk about some resources
and where to go for help. Next slide, please. Please note that the 2019 materials providing
information on MIPS Quality performance category are available on the Quality Payment Program
Resource Library. We encourage reviewing these resources if
you have questions on quality requirements and measures. We’ll continue to communicate any future postings
and upcoming support calls. Additionally, the Help and Support page on
the Quality Payment Program website contains links to materials such as videos, webinars,
and online courses, as well as other items to help with reporting and development. Next slide, please. And here’s some additional resources. The Quality Payment Program Webinar Library
contains recordings, slides, and transcripts for past webinars, including the 2019 CMS
Web Interface User Demonstration that was held in November and the CMS Web Interface
Kick Off Call, held last December. The recording, slides, and transcript for
the January 15th, 22nd, 29th, and February 5th calls are also available on the library. Please note that it may take 1 to 2 weeks
to post the presentations to the library following a webinar. Next slide, please. And here’s some additional resources for the
Medicare Shared Savings Program and Next Generation ACOs. This slide contains links for resources available
for the Shared Savings Program and the Next Generation ACO Model. Next slide, please. And this slide shows how you can get additional
assistance. So please refer to the contact information
listed on the slide. Next slide, please. Now, just before we head to the Q&A portion
of the call, if you’re interested in providing feedback and collaborating with CMS on the
Quality Payment Program, we encourage you to participate in our Human-Centered Design
efforts. To get involved, please e-mail your name,
title, topic of interest, and organization to the e-mail address on the slide. And now I will hand things over to Kayte to
begin the Q&A portion of this webinar. Great. Thank you, Sandra. Alright, so, now we are beginning the Q&A
portion of this webinar. If you would like to ask a question, please
submit it through the questions tab on your screen, and we can read it out loud, or, of
course, if you’d like to ask a question over the phone line, please raise your hand as
shown on the screen, and we can unmute your line. Alright, so, the first question asks, “At
one of the previous support calls, you said that for PREV-12, a statin allergy or intolerance
had to be documented in the measurement year. Our providers add statin to the allergy or
intolerance list at the time that the allergy or intolerance is needed and because this
is a living document, the allergy or intolerance is available to the provider at the point
of care. Will this still meet the measurement requirement?” Good afternoon. This is Deb from the PIMMS team. And I want to point you to page 14 of the
posted specification. There are a few things to keep in mind with
the denominator exception for PREV-13. And also to clarify, this is for PREV-13,
the statin measure. The first guidance note does have to do with
mapping. So, for mapping from the EHR, when an acceptable
drug allergy code is found, you would look for the drug classification with a yes conditional. These drugs can be used as a denominator exception
if present in the patient’s record, accompanied by an appropriate conditional reason why the
patient isn’t taking the drug. For example, an adverse effect, allergy, or
intolerance to statin medication. But then, further down in that guidance, you
will also find that the denominator exception should be considered active during the measurement
period. So the fact that somebody may have been allergic
to a statin 10 years ago is not a reason for statin medication not being prescribed. It should be something that is, again, considered
active during the measurement period. So your documentation would need to reflect
that in some shape or form. Thank you. Great. Thank you. Alright, your next question asks, “For MH-1,
if there are two PHQ-9 results documented on the same date, which result is used?” Hi. This is Kayte from the PIMMS team. So, you would enter the first instance where
the PHQ-9 is greater than 9. Thank you. Great. Thank you. Alright, next is also about MH-1. For MH-1 timing for exclusion, is it any time
in the patient’s history prior to the end of the map or it is only during the denominator
identification period, up to the end of the MAP? Hi. This is Kayte again. So, the exclusions encompass the denominator
identification period through the measure assessment period. So the exclusions do not apply to any time
in the patient’s history. It’s truly limited to those two dates. And just to emphasize, they do require that
the diagnosis for one of those exclusions is active. So there must be — Excuse me. The diagnosis on the patient’s problem list,
a diagnosis code description listed in an encounter, or documented in the progress note
indicating the patient is being treated or managed for the disease or condition. So, just to reiterate, this timeframe could
be different for each patient, depending on that index date and then the subsequent measure
assessment period. Thank you. Great. Thank you. Alright, another question for PREV-13: “In
the event a patient is on the statin during the measurement period, however, the patient
develops an intolerance during the measurement period, do they report the taking of statin
or the intolerance?” So, this is Deb from the PIMMS team again. And since we’re talking about a denominator
exception, denominator exceptions do not have to be selected. So, therefore, if you have determined the
patient was either taking a prescribed statin therapy during the measurement period or was
prescribed statin therapy during the measurement period, you can select “Yes, the patient is
taking or were prescribed statin therapy.” Thank you. Great. Thank you. Alright, regarding exclusions for long-term
care. “If we have documentation –” Oh, sorry. “If we have documentation, in the medical
record, that the patient is permanently residing in a long-term care facility but has no POS
code, can we exclude the patient from these measures?” Hi. This is Angie from PIMMS. Yes, you can. You are not required to have documentation
of the Place of Service Codes. They are provided in the measure specifications
just to help you determine the type of long-care facilities for the exclusion and to help you
locate the place in the medical 4 record where there may be documentation that
the patient resided in long- term care during the measurement period. So you may select it if you have documentation
that they were in a nursing facility, custodial-care facility, hospice, or intermediate-care facility/intellectual-disabilities
facility. And note that the denominator exclusion does
not include Place of Service 31 for skilled care. Thank you. Great. Thank you. Alright, and just a reminder to everybody
on the phone line, if you’d like to ask a question over the phone, please raise your
hand on the GoTo menu, and we can go ahead and unmute your line. So, at the moment, we do have one question
on the phone line. It’s by Lauren Sweeny. So, Lauren, we’re unmuting your line, and
you can go ahead. Lauren Sweeny, you can go ahead and ask your
question. Okay, thank you. So, I’m wondering — this is in regard to
the hypertension measure. If the diagnosis is in a resolved status on
the problem list during the measurement period and the only reference to that diagnosis is
a lab claim, should that be considered a resolved or not resolved? So the providers are not using that anymore. They’ve put it into a resolved category. So, this is Kayte from the PIMMS team. For hypertension, the Denominator Confirmation
calls for patients with the documented diagnosis of the potential hypertension within the first
six months of the measurement period or anytime prior to the measurement period but does not
end before the start of the measurement period. So if the hypertension resolved during the
measurement period, that patient should still be included because it was still active during
the measurement period. Does that help clarify? Not really. So, there’s no resolve date. Should I assume that it’s still — Even though
it’s been labeled resolved, if there is no date, should I assume that it’s not resolved? In terms of for — your measure documentation
would need to support the information that’s submitted. So if you don’t have documentation truly supporting
that diagnosis is resolved, it would likely still be viewed as an active diagnosis, but,
again, that is something that would be more up to your organization to determine if you
have the appropriate medical-record documentation to support whether the diagnosis was active
or resolved and subsequently report appropriately. Okay. Okay, thank you. Great. Thank you. Alright, your next question asks, “For PREV-13,
is Repatha able to be used as a statin?” So, this is Deb again, from PIMMS. And I’m going to point you to page 6 of the
posted specification. There is a numerator note that refers to statin
therapy. Basically, only statin therapy meets the measure
numerator criteria, not other cholesterol lowering medications. So you would need to determine if the medication
that you are referring to is considered statin therapy and not just cholesterol lowering
medication. Thank you. Great. Thank you. Alright, next question asks that, “On one
of the slides, it indicated that claims data could be used to support PREV-6 but that medical
record documentation needed to be there to support. What about
5 patient reported documentation? If a patient states that they had a normal
colonoscopy within the required timeframe, do we have to attempt to locate the documentation
to support?” This is Angie. I’d like to clarify the slide. And it was not saying that claims could be
used. We can bring that up again, if we like. But it is saying that claims data can be used
to aid you in finding the quality action, meaning medical record documentation that
the colonoscopy was performed, you know, with the date and so forth. So, really, the answer is, no, claims data
cannot be used solely to confirm a colonoscopy. And then you asked about the patient-reported
colonoscopy. And for that, it just needs to have the year
of the colonoscopy and the type of test, of course, and the result, whether it’s normal
or abnormal or some type of result documented. Thank you. Great. Thank you for that clarification. And you can see that we have pulled that slide
up for their reference. Alright, so, we will go back to the phone
lines. So, Joseph Bartman, we are unmuting your line. And, Joseph Bartman, you can go ahead and
— your question. Thanks. So, in relating to influenza, if we have a
provider who’s documenting on multiple occasion that the patient is declining all recommended
health maintenance, including immunizations, does that meet the intent of patient refusal
as it relates to the influenza vaccine? Hi, this is Jamie with the PIMMS team. Can you please submit this question into the
Help Desk at [email protected], and we can go ahead and take a look at this and give you
a response? No problem. And I can put the actual what they wrote in
the chart so you guys clearly can see what it’s stating, but thank you. Okay, thank you. Alright, great. Next question concerns PREV-12. It asks to, “Please confirm if the depression
screening has to be documented on the same date as the office visit.” Hi, this is Kayte from the PIMMS team. So, I’m going to direct this question to page
10 of the measure specifications. So, a patient may have access to the depression
screening tool in advance of the appointment. However, the depression screening results
must be documented on the date of the encounter, which is the date of the appointment. So the result must be reviewed and verified
and documented by the eligible professional in the medical record on the date of the encounter
to meet the screening portion of the measure. Thank you. Great. Thank you. Alright, next question asks for MH-1: “If
we don’t have enough beneficiaries that meet the minimum requirements, what is the process
to fulfill the protocol?” Hi, this is Ozlem. If you have less than 248 beneficiaries ranked
for a measure, you must report required data for all beneficiaries in that measure sample. So if you have only 50 beneficiaries in a
measure sample, you need to report the required data for those beneficiaries that are in the
sample. Thank you. Great. Thank you. Alright, we will go back to the phone line. Lucilia DaRosa, we’re unmuting your line. So, Lucilia DaRosa, you can go ahead. Hi. How are you. Great. Thank you. You may go ahead. I actually just have a question. We have a member that’s in the PREV-5 measure
that’s actually holding up the whole measure. In the system, they have him listed as a female. His name is [REDACTED]. We’ve submitted a ticket to the QPP system,
but according to them, we got a response back saying we can edit the demographic information
to the CMS Web Interface, which we’ve done, but it’s not taking it, so we submitted a
ticket to the Help Desk, I believe, on February 7th. And we haven’t heard back. So I don’t know if there was any way that
someone can actually look into this because it’s holding up that measure. Hi, could you please repeat that question? We couldn’t hear the full question. Yes, and this is Sandra. Please do not share any protected information. Mm-hmm. We just want to know who can expedite the
ticket. Because, like I said, we submitted it again
to QPP at CMS on February 6th, and we haven’t heard back. Hi, this is Ozlem. I believe you said you had opened a third
ticket and you haven’t heard back. If that’s the case, if you could share the
Service Now ticket number in the chat, we will look into that and get back to you. Hope that helps. Alright, great. Thank you. Again, Lucilia, if you could submit your Service
Now ticket, we will forward that. Alright, next question is on PREV-13: “Can
you please repeat the limited period that denominator exceptions are exceptional?” Absolutely. The guidance is provided on page 14 of the
posted specification. Documentation of the exception should be active
during the measurement period. Thank you. Great. Thank you. Alright, next is a clarification on the PREV-7
clarification given today. They called into the QPP Help Desk to verify
that claims data can be used in verification, which was confirmed. The issue was then brought up when analytic
software was automatically closing this measure based on claims data. It is our understanding that this is not acceptable
unless prepopulated in QPP. But when they called the Help Desk again,
they were told it was acceptable. Please, can you clarify? Hi, this is Jamie with — Hi, this is Angie from — Sorry, Jamie. I was just going to say, I have the case up
that was in question, and it looks like there was maybe some misunderstanding from another
team. So we could offer to re-open that and address the question through the Help Desk,
unless you had something to add, Jamie. Sorry. Thank you. That sounds like a plan. Thanks. Okay, great. Alright, we’ll get back to the phone line. Shelley Simpson, we’re going to unmute your
line. So, Shelley Simpson, you can go ahead. Hi, this is in regards to PREV-7. Can you guys hear me okay? Yes, you may go ahead. Okay, I know previously in this call, when
people were saying patient had reported, you had specified for PREV-7 that with some of
the more questionable ones, they had to have the month, but according to the actual document
here, documentation of patient-reported previous receipt of influenza immunization is acceptable
therein the flu season. Our scenario is, for core measure, we actually
set up our screening where it specifically says if a patient comes into the hospital,
you know, have you had a flu vaccination this season and then the patient, they answer however. So, if I have a scenario where the patient
comes in on October the 31st and this screening specifically says, “Have you had the flu immunization
this season,” and the patient says, “Yes, had this season prior to admission,” is that
still unacceptable? Do they have to say, “I had it in September,
October”? Because according to guidelines, that’s okay
if they specify this season and it’s during the season. Hi, this is Jamie with PIMMS. If possible, could you also submit this question
into the Help Desk question at [email protected] so we can take a look at that and really sort
of read through that scenario? Okay, thank you. Thank you. Okay, great. As a reminder, we are accepting phone questions,
so please just go ahead and raise your hand and we can unmute your lines. In the meantime, we had one more question
come in regarding an answer that was earlier provided on MH-1 regarding exclusion criteria
timeframes: “On page 10 of the narrative spec for MH-1, the spec says that the denominator
exclusion diagnoses can occur anytime prior to the end of the measurement assessment period,
so can you please clarify?” Hi, this is Kayte from the PIMMS team. So, yes, just wanted to address this again. Also, on page 10 of the measure specifications,
it does state that there must be an active diagnosis associated with one of those denominator
exclusions. So, just to reiterate, an active diagnosis
is defined as either on the patient’s problem list, diagnosis code, description listed on
the encounter, or is documented in the progress note indicating the patient is being treated
or managed for the disease or condition. So they have to have that active diagnosis
during the denominator identification period through the end of — or up until the measure
assessment period. So you have that 12 months, plus or minus
60 days as initiated by the index date to determine whether or not there’s an active
diagnosis applicable to one of those exclusions. Thank you. Great. Thank you. Alright, next question concerns PREV-7: “In
the event that a patient receives a flu vaccine during the flu season and received palliative
care at the end of the performance year, are they then required to be removed from the
denominator?” Hi, this is Jamie with PIMMS. Thanks for the question. Yep, looks like this could be a medical exception. Therefore, as long as that is documented in
the medical record during the flu season, that would be applicable. Thanks so much. Great. Thank you. Alright, next question. “For PREV-13, does the ASCVD or diabetes
diagnosis have to be active during the measurement period? For example, if a patient had a diabetes diagnosis
that was resolved in 2018 but they had an LDL greater than 70 in 2019, would that patient
still qualify for the measure?” So, this is Deb, and I had that specification
pulled up. Here we go. What I would recommend for PREV-13 is to definitely
go through in a step-by-step fashion to determine the denominator eligibility. So the first thing you are going to determine
is if they have a clinical diagnosis of ASCVD. If you are getting all the way into patient
population number three, patient population number three on page six does say that they
have type 1 or type 2 diabetes. The measurement here — and let me go — if
you go down into the actual denominator criteria of each of those, it will provide some additional
information. So, for the criteria for diabetes and patient
population three on page 12, it does say that the diagnosis of diabetes is defined as any
history of diabetes prior to or during the measurement period. So, again, I would look at those specifications. If it doesn’t give you the specific time period
within the first couple of pages, if you get into the submission guidance, the denominator
and the numerator, those time periods should be identified there. If you have additional questions, please feel
free to submit another one, and I will try to get to those questions, as well. Thank you. Great. Thank you. Alright, your next question asks, “With
measure MH-1, is it acceptable to report less than 248 patients if the small number is the
only number of patients who satisfy the measure?” Hi, this is Ozlem. If you have less than the minimum required
number of beneficiaries, which is 248, please do complete all the beneficiaries that you
have in that measure sample to meet the reporting requirements for the measure. Thank you. Great. Thank you. Alright, your next question asks, “If we
have recorded through CMS claims that the patient is deceased, should we skip them or
does the death need to be indicated in the medical record in order to skip the patient? It was not indicated in the medical record
at the time, as it is out of network.” Hi, this is Kayte from the PIMMS team. I think we might need some additional information
in order to answer this question appropriately, so we’re actually going to direct this submitter
to submit their question to [email protected] Thank you. Great. Thank you. Alright, your next question asks, “Historically,
guidance from CMS was provided that patient reported colorectal screening required month
and year along with results from the chart. Currently, we have now heard on a couple of
recent calls that it is now only the year that is required. Can you clarify if the month is no longer
required?” Hi, this is Angie with PIMMS. I’m sorry. Could you repeat which measure that question
was for? Hi, Angie. It’s for colorectal screening. Okay. PREV-6 for colorectal cancer screening. In the — okay. It tells in the measure specifications what
is required, and it’s going to depend on the type of test to determine if it is in the
proper timeframe. Colonoscopy, it just has to be during the
measurement period or the nine years prior. If it is a different type of test that might
require to show the months to substantiate that it was in the proper timeframe, then
it would be. I’m sorry. I think all of these are for years. So, if you look on page eight under the numerator
guidance, it does say that the patient reported requirement is date in parentheses here and
type of test and result or finding. So you can find out then on page eight. Thank you. Great. Thank you. Alright, I believe, Jamie, you would like
to clarify a question about influenza high-dose vaccine from September 29, 2017, which was
deferred as the patient will get PCP. Yeah, thanks so much. This is Jamie with PIMMS. I’m not sure exactly the nature of the question
if you’re speaking to numerator compliance, so if you could either clarify the question,
the Q, or go ahead and submit a Help Desk question at [email protected], that would be
really helpful, and we’ll go ahead and get a response for you. Thanks. Great. Thank you. Alright, your next question asks, “For DM2,
if the date and result of an HGB A1c is pre-populated in Lighbeam for a beneficiary, but you cannot
locate medical records for that service, how should this be classified?“ This is Deb from the PIMMS team, and you may
need to provide some additional information on this if I don’t quite answer your question. Basically, your medical record documentation
needs to be able to support for the numerator compliance that the patient had one or more
hemoglobin A1c tests performed during the measurement period. You also need to be able to record the most
recent date the blood was drawn, and that includes the month, date, and year. And then additionally, to be able to record
the most recent hemoglobin A1c value. If that doesn’t answer your question, if you
could go ahead and provide some additional detail, and I’ll try and come back to that. Thank you. Great. Thank you. We will let you know if more detail is provided
that we can discuss on today’s call. Also, as a general reminder to everybody on
the phone, if you do have a question that you would like to ask, please feel free to
submit it through your chat box and we can read it out loud, or as always, you can go
ahead and raise your hand. At the moment, a final question asks, “Historically,
guidance from CMS was provided that patient reported colorectal screening required month
and year.” Sorry, this says already asked, but it looks
like they missed the question. Can you please clarify whether the month is
no longer required and only the year is? This is Angie. Could you submit our question to the QPP Help
Desk and we can get you an exact answer? I had quoted the patient reported requirements
and then the specs also saying the note indicating the date the screening was performed and the
results or findings would be for non-patient reported, but we could look into this and
make sure we have the correct answer for you if you would submit a ticket, please. Thanks. Alright, great. Thank you. Again, the question period portion of the
seminar is open for another 15 minutes. If you’d like to ask a question, please submit
it. We’ll give it a few minutes to see if anything
new comes in. Alright, we have a question over the phone
line. Nicole Caliendo, we’re un- muting your line. Alright, so, Nicole Caliendo, you may go ahead. Oh, I’m sorry. I clicked on the hand by mistake. Not a problem. Thank you anyway. Alright, your next question concerns HTN-2. “If the patient has no diagnosis of I10
essential hypertension but has a history of unspecified hypertension or any hypertensive
disorder that is not specifically I10, will the patient qualify for this measure?” So, this is Kayte from the PIMMS team. We would encourage you to take a look at the
hypertension coding document for the applicable diagnosis associated with confirming the diagnosis
for this measure. So, the measure does call for essential hypertension,
and they think we would need some more detail in regards to your specific question to confirm,
you know, specifically whether or not that meets the intent of the measure. But just to reiterate, they do need a documented
diagnosis of essential hypertension within the first six months of the measurement period
or any time prior. And then, again, take a look at that coding
document to ensure that the diagnosis is present there in order to confirm. Thank you. Great. Thank you. Alright, next questions asks, “If the last
vitals of the year are clearly entered in error, for example, 18 over 65, do you enter
it as values or move to those previous?” So, this is Kayte from the PIMMS team. I believe this is actually a case that’s open
currently within the Service Center, and it’s taking a little bit of investigation on our
part. So, we would ask that you stay tuned for response
that opens Service Center question in order to receive an accurate response on this one. Thank you. Great. Thank you. Alright, your next question concerns PREV-13. “If a statin medication was active in 2017
or 2018 but was discontinued prior to 2019, would the medication still count?” So, this is Deb from the PIMMS team, and the
answer to that is no. If you have been able to confirm that the
patient would be considered denominator eligible for the measure, you would need to find some
time within the 2019 program year that the patient was actively
using or received an order or prescription for statin therapy. Thank you. Okay, great. Thank you. Looks like we do have one question on the
phone line. So, Ashley Juhl-Darlington, you are now unmuted. So, Ashley Darlington, you may go ahead. Okay, can you guys hear me okay? Yes, you may go ahead. Okay, great. So, I asked a question earlier about the MH-1
fulfilling the protocol. What I’m running into, and hopefully I can
get clarification, is if a patient is diagnosed with depression during the denominator identification
period and then the providers are not following up with the PHQ-9. Those patients are getting skipped. So my question is, is how do we then fulfill
this requirement when we are continually getting patients skipped? So, this is Kayte, and we need a little bit
further clarification. So, are you saying that they had the appropriate
diagnosis but did not have an initial PHQ-9 during the denominator identification or they
didn’t have a follow-up in the 12 months plus or minus 60 days? Yes, exactly. So, in the follow-up period. Generally, in the annual wellness, there is
an initial PHQ, but then the follow-up. So if there’s no follow-up, then those patients
are continually skipped. So I’m having a hard time fulfilling the minimum
requirement. Sure. I mean, purely based on the measure specification,
they do have the appropriate diagnosis with that initial PHQ-9 that marks the index date. The numerator does require documentation of
that PHQ-9 in the measure assessment period, which is that 12 months plus or minus 60 days
from the index event. So, if they did not have one or more PHQ-9
administered during the measure assessment period, you would have to report no for those
patients, and it would be considered performance not met for those folks. Okay, so continue along even though I’m getting
multiple skips? Right, yep. If there’s not documentation to support that
they received that follow-up PHQ-9, there’s no other options for reporting other than
yes or no as to whether it was completed. Okay, and so then my second question is, once
I get to the end of this reporting, then what happens? Is it just meet that there’s not a minimum
that’s met? So, this is — This would be a question — Kayte, can we go back just — and only because
you’re talking about skipping, and I think what Kayte’s trying to say is, you’re really
not skipping a patient, but I think what might be happening — again, if you have somebody
that meets the denominator criteria based on the diagnosis, are you also finding during that index period,
a PHQ-9 greater than 9 to do that completion of confirming denominator eligibility? Well, sometimes. I mean, not always. Okay, so if there is not — and that’s where
the difference lies. So, if you have somebody who’s denominator
eligible, you have the diagnosis, you have the PHQ-9 greater than 9, and finding in the
follow up, they do not have a PHQ-9 less than 5, that’s not a skip. That would be a performance not met. On the other hand, if you have a denominator,
you’ve confirmed the diagnosis, but there’s no PHQ-9 greater than 9, that one would skip. And in that case, what a lot of people run
into is they will go through their entire sample, and because maybe there’s not a PHQ-9
used at all or they don’t find that many PHQ-9 greater than 9 results, that results in a
lot of skips, and you may have to work your way through that entire patient sample until
you’ve reported on 100%. We have in the past had some people that they
don’t use the PHQ-9 at all, so they skipped their entire patient sample. And that’s fine. You’ve completed it. You’ve done what you could do. Okay, great. That answers my question. Thank you. Thank you. Great. Thank you. Next question concerns MH-1: “If the patient
answers all of the questions but does not tell you the score and the provider mis- calculates
the initial results in the notes during the audit, can it be manually re-calculated and
that number used?” Hi, this is Kaytee from the PIMMS team. This particular question, we would also suggest
sending to [email protected] Thank you. Great. Thank you. Alright, your next question asks for clarification
for the 2019 MH-1 coding document. It says that it doesn’t list an ICD-9 codes
from the denominator but does list ICD-9 codes for denominator exclusions: “Are ICD-9s
accepted for the denominator, and if so, where can those be found?” This is Kayte again. So for MH-1, you would need the appropriate
medical record documentation as outlined in the measure specifications to support what
you’re reporting. So, in terms of mapping to the coding documents,
those are all-inclusive if you are mapping to an EHR. However, any medical record documentation
can be used to support the appropriate diagnosis for the measure. So, with that said, there are some instructions
within the narrative specifications on specific language and the diagnosis code usage. That can be found on page nine of the measure
specification. So, the following are ways that you can use
to confirm the diagnosis of major depression or dysthymia, either a diagnosis code on the
encounter or problem list, and that’s regardless of the vendor assigned description of the
code. You can also look for the words “major depression,
major depressive disorder, dysthymia, dysthymic disorder, pervasive depressive disorder”
on the progress notes or problem list to confirm the diagnosis. In addition to paper records, the description
diagnosis can be used with the option to confirm by billing code. We would suggest, you know, ensuring your
documentation maps to those appropriate ways to confirm the code. And then if you need additional assistance, you can
always submit that question to [email protected] and we can help you through that further. Thank you. Great. Thank you. Alright, your next question asks for clarification
on PREV-6. They note that if there’s an encounter in
May of 2019 which states that there’s a colonoscopy eight years ago in normal, would it be appropriate
to capture this screening and use the year 2011? Hi, this is Angie with PIMMS. I think that was probably a question that
I can answer. Can you repeat the measure and the question
for me? Of course. It’s for PREV-6. It asks, “if there was an encounter in May
of 2019, which states that there’s a colonoscopy eight years ago and normal, would it be appropriate
to capture this screening and use the year 2011?” As long as the medical record documentation
can substantiate that the colonoscopy was performed during measurement year or the nine
years prior, then, yes, it can be used. Thanks. Great. Thank you. Alright, and your next question is for HTN-2
when the measure specs use the words diagnosis of hypertension, however the coding documents
use the word essential hypertension. Is hypertension only enough to meet the denominator? So, this is Kayte from the PIMS teams. Again, the denominator does call for a diagnosis
of essential hypertension, so just verifying with the word hypertension in your medical
record would not truly be enough to confirm the appropriate diagnosis. So you would need to ensure, I mean, take
a look and see if you have further documentation that would be able to confirm that diagnosis
of essential hypertension within the appropriate timeframe for the measure. Thank you. Great. Thank you. Alright, and your next question asks, “If
the provider documents hyperlipidemia and the code is for familial or pure hypercholesterolemia,
is that acceptable even though the correct code is used?” This is Deb from the PIMMS team, and because
this is getting into some of the specific documentation requirements, I would recommend
going ahead and opening up a Service Now Help Desk question. The thing about the coding is, the coding
is considered all-inclusive. You can use the coding to confirm that the
patient should be meeting the intent of the measure, and in this case, the intent of one
of the populations considered denominator eligible. And this may go back kind of to a question
that was asked last week, and we will continue to provide clarification on this. There are times we can’t tell you exactly
what a provider meant when they wrote something in a medical record, and it may be necessary
for you to confirm what was intended by that documentation. In no way, shape, or form are we suggesting
that medical records are updated at this point in time, but just being aware that there are
some things in the medical records that if you’re not sure what the intent is, we certainly
can’t answer that. And you would want to ensure that you have
the proper documentation to confirm the patient should be included in that denominator. And the main reason for that is just to ensure
that you’re being held accountable to a quality action that is relevant for that patient. So if you have additional information, please
feel free to open up a Service Now inquiry, and we can
provide some additional guidance or point you to the measure specification for your
specific case. Thank you. Okay, great. Thank you. And it looks like that’s all the time that
we have for Q&A today, so I will pass it back to Sandra to close out. Thank you, Kayte, and thank you, everyone,
for joining us today. The slide deck recording and transcript from
today’s call will be available on the QPP Webinar Library in the next two weeks. As a reminder, our next support call is scheduled
for next Wednesday, February 26th from 1:00 to 2:00 p.m.
Eastern Time, during which we’ll cover assignment and sampling frequently asked questions as
well as frequently asked measure questions for MH-1 and PREV-13. We hope you’ll join us. Thank you.


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