CMS Web Interface Questions Answered

Welcome to the "CMS Web InterfaceQuestions Answered" page.

Below are questions that have either been posted to the QualityNet Help Desk or asked of Cana Howard, our Lead Abstractor. If you have CMS Web Interface questions that were asked and answered and would like to share, please send them to James Malayang. As for emailing questions to Cana Howard, make sure you have the correct address: cmshims@med.umich.edu.

 

 

For CARE-1, what documentation can be used to confirm the CMS-provided discharge dates? Must we have the actual Discharge Summary in the chart or, in the case of discharges from entities outside of our ACO, can the patient self-report the discharge? (2/28/2018)

Hi Cana

Thank you for your question regarding CMS Web Interface Measure CARE-1: Medication Reconciliation Post-Discharge.

You are to use documentation within the patients health records to verify the prefilled discharges (+/- 2 days). There must be a specific discharge date noted in the medical record documentation. It could be from the patients discharge summary. If it is patient reported, it will need to be documented within the patients chart. In the event of an audit, this documentation will be required.

Thank You and have a great day.

Ngozi Uzokwe
PIMMS Team

--QPP Service Center Production

 

For DM, we have a beneficiary who is blind. Is she an eligible for exclusion? The patient's rank for DM is 139. #CS0104966 (2/27/2018)

Thank you for your request for a CMS Approved Reason to skip a beneficiary included in your 2017 sample for web interface quality measure submission. The following request has been approved: Patient(s) Rank: 139 Measure: DM-7: Diabetes: Eye Exam

Please maintain this case resolution as proof that the CMS Approved Reason to Skip has been approved.

Thank you,
PIMMS Measures Team

--QPP Service Center Production

 

IVD-2, may we please have a denominator exclusion for a patient who is allergic to aspirin? The rank is 535. #CS0093339 (2/22/2018)

Close notes: Thank you for your request for a CMS Approved Reason to skip a beneficiary included in your 2017 sample for web interface quality measure submission.

The following request has been denied:
Patient(s) Rank: 535
Measure: IVD-2: Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic
Reason for Request: Patient is allergic to aspirin

Thank you,
PIMMS Measures Team

--QPP Service Center Production

 

For PREV-7, If the patients chart says “receives from VA” but doesn’t have a date, will it work? (2/19/2018)

It’s my understanding that you need to have at least a month and year because you need to verify that the influenza vaccination was administered between 10/2016 and 03/2017.

--Cana

 

For MH-1, I have a chart that is an EMR record and it states “Depression, Controlled (F32.9)." In the spreadsheet I look up F32.9 denominator code and the description on the spreadsheet is “Major depressive disorder, single episode, unspecified”. Checking the diagnosis code on the sheet and the correct diagnosis is there, but in the EMR it just says depression, so do I use that even though it doesn’t say “major” but it has the appropriate diagnosis code next to it for billing? (2/16/2018)

If the diagnosis code is there, then we pass the measure. But if there's no code AND the wording does not have "major depression" then we fail.

--James and Cana

 

For HTN-2, How would I handle for a patient that goes to ER for treatment, only saw PCP twice in 2017 January and March, the blood pressure? Wasn’t there an exclusion at one point for ER visits? Do I put the last ER visit BP? Of course all of the visits are over 140/90. Jenny S. (2/16/2018)

Hi Jenny,

Assuming that the patient has an active diagnosis of essential HTN during 2017, you would take the most recent blood pressure from the most recent outpatient visit. Does that help?

Cana

--Cana

 

For MH1, I have a patient that takes Cymbalta for Fibromyalgia. The notes actually say that. There is no history of depression. May I have an exclusion ticket on that? #CS0084917 (2/16/2018)

Since the patient has no history of depression, please choose the "Not Confirmed-Diagnosis" value.

--Cana

 

For PREV-13, are you adding denominator exclusion when a pt refused statin treatment? And, did I hear not to use the N/A option as it’s not an option in the tool? We have questions that are not a straight no or yes to “is pt qualified”. This is in regards to finding the chart, but the pt is not managed at all by the provider only saw a specialist and can’t inactivate in the EMR. In essence, I can find chart, but can’t confirm any diagnosis or have any notes to hospice, death etc. To me this is NA as maybe they are not qualified. Tina C. (2/15/2018)

Hi Tina,

First, patient refusal is not an exception – only adverse reaction/allergy - and the case you describe should be abstracted as the patient is not taking a statin. I would include a comment, however that the patient refused.

To my knowledge, if you find a chart, you cannot omit the patient from the sample. If the patient has no other providers within POM ACO, you would have to answer “no” to all of the diagnosis and statin questions and the patient would be a “fail”. Again, I would include a short comment describing what you mention in the note below. Because this is an issue many people have come across, however I’d like to ask James if he has seen anything on the webinars that discusses this issue and, if not, I’d like to ask that he submit a ticket to confirm that we can’t exclude such patients.

Does this help?

Cana

--Cana

 

For MH-1, we have cases where we have not been able to confirm if the problem list description can be supported by a diagnosis of major depression, including instances of locating a diagnosis of major depression prior to index or after. The submission guidance states that “Active diagnosis is defined as either on the patients problem list, diagnosis code listed on an encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the measurement period”. What would be the best way to report on the following two examples? #CS0086948 (2/14/2018)

Example 1: Anxiety and depression on the problem list as active throughout the index. Onset date associated with description 2013. ICD 9 code attached for DX was 300.4. Description within claim billed indicates :Anxiety with depression. Code 300.4 is a part of the denominator value set for MH1. Description in value set for MH1 describes it as: Dysthymic disorder EMR documentation : DX 300.4 resolved 6/13/2016 Anxiety with depression F41.8 begins 6/13/2016 Problem list continues to include: anxiety and depression throughout index 2017 major depression coded and problem list is updated to reflect

Example 2: Problem list prior to and throughout index period states depressive disorder with onset: 11/7/2012 Not able to locate a ICD 9 code to confirm if code would be included or not Multiple PHQ9 completed during index with score that provides description of Major depression but it is never billed or defined in the problem list as major depression. Anxiety and depression in assessment billed 6/6/2016 F41.9 not a part of the MH1 denominator value set 6/27/2016 F32.8 other depressive episode found on assessment billed – does not appear part of the denominator value set for MH1

Hi James,

Response 1: If the patient had an active diagnosis of major depression or dysthymia at any time during the denominator identification measurement period (12/1/2015 to 11/30/2016), then they will qualify for the denominator of the measure. If the patient does not have a PHQ-9 score greater than 9 during the denominator identification measurement period then they will be skipped and replaced.

Response 2: When submitting data through the CMS Web Interface, the expectation is that medical record documentation is available that supports the action reported. Coding or billing information alone is not sufficient documentation. A diagnosis of "depression" alone will not suffice. However, in the event of an audit we would accept the diagnosis of "depression" only if it is paired with an eligible code, such as F32.9 (Major depressive disorder, single episode, unspecified), on the patient problem list. If this patient did not have an active diagnosis of major depression or dysthymia during the denominator identification measurement period (12/1/2015 to 11/30/2016), then you should select "NO" and the patient will be skipped and replaced.

Thank you,
Jessica Schumacher
PIMMS Measures Team

--QPP Service Center Production

 

For CARE-1, Does a QRO have to have the actual discharge documentation to answer "Yes" to the question "Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?" Or is it permissible for the patient to self-report the discharge at the return visit and the provider documents it in the return visit note? We have several patients who were discharged from a nearby hospital that is not part of our group. (2/13/2018)

No answer yet.

 

For CARE-1, 1) If a patient is discharged from an inpatient hospital to an inpatient rehab, does the rehab H&P qualify as the discharge medication reconciliation or does the reconciliation verbiage need to be specifically mentioned? 2) If a provider discusses specific discharge meds during an encounter, does that qualify as a complete discharge medication reconciliation? (2/13/2018)

No answer yet.

 

For PREV-5, we have a chart in NextGen for a patient, however all encounters identified are for extended care services. We have no actual documentation of visits. We only have claims billed, which the codes for service billed is part of the data set. Not sure of the best way to report. If you can’t find even one of the discharge dates, is the whole case is skipped? #CS0084921 (2/12/2018)

Thank you for your question regarding CMS Web Interface Measure PREV-5: Breast Cancer Screening.

Though the patient may not have been seen at your facility, due to how patients are chosen for inclusion in a disease module or patient care measure sample, the patient was seen at least twice by participant TINs affiliated with your ACO during the measurement period. Specifically, beneficiaries were assigned to your ACO and must have had two or more primary care services within the ACO to be sampled into the disease module or patient care measure. Since your organization is deemed accountable for such a case, you may not select 'not qualified for sample' under this circumstance.

Thank you and have a great day.

Ngozi Uzokwe
PIMMS Team

--QPP Service Center Production

 

When abstracting PREV-13, there doesn’t appear to be a field to indicate the exclusion of pregnancy, breastfeeding, rhabdomyolysis, statin allergy, liver disease, or ESRD. How should this information be documented in the WI? #CS0084920 (2/8/2018)

Thank you for your question regarding CMS Web Interface Measure PREV-13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease.

For the PREV 13 measure, Denominator exclusion option for risk category 1 and 2 will be in column CP and CR (drop down menu). There is no option for this in risk category 3 as it should have been captured in column CP and CR.

Thank you and have a great day.

Ngozi Uzokwe
PIMMS Team

--QPP Service Center Production

 

For CARE-1, When reviewing the charts and medical records for reconciliation, does there need to be the words "discharge" and "reconciliation"? Or if medical reconciliation was done, regardless of the verbiage, would it pass?

 

Most of our providers, so far, have addressed all meds from the discharge notes. But in many cases, I have one medication that was not addressed. With not 100% of every med addressed, many are "no" in the measure for us. (2/8/2018)

Thank you for your question regarding CMS Web Interface Measure CARE-1: Medication Reconciliation Post-Discharge.

The medication reconciliation is specific to post discharge, and needs to be easily identified as such.

The intent of CARE-1 is for the prescribing practitioner, clinical pharmacist or registered nurse to reconcile discharge medications with outpatient medication on or within 30 days of discharge. The CARE-1 measure specification defines medication reconciliation as a type of review in which the discharge medications are reconciled with the most recent medication list in the outpatient medical record. Documentation in the outpatient medical record must include evidence of medication reconciliation and the date on which it was performed. Any one of the following evidence meets criteria:
(1) Documentation of the current medications with a notation that references the discharge medications (e.g., no changes in meds since discharge, same meds at discharge, discontinue all discharge meds), or
(2) Documentation of the patient's current medications with a notation that the discharge medications were reviewed, or
(3) Documentation that the provider "reconciled the current and discharge meds," or
(4) Documentation of a current medication list, a discharge medication list and notation that the appropriate practitioner type reviewed both lists on the same date of service, or
(5) Notation that no medications were prescribed or ordered upon discharge.

Example 1: Hospital discharge notes and medication list are found within the medical record

A: If no other information is provided about reconciling the discharge medications with the outpatient medications then this does not meet any of the afore mentioned requirements and should be coded as a "No".

Example 2: Medical record notes that patient was discharged from the hospital and in a following sentence it notes that medications were reconciled.

A: This may meet requirement #3 if the note specifically indicates that they reconciled the discharge medications with the current medications. This would only meet requirement #4 if there is also documentation of the current/outpatient medication list and the note indicates that both the hospital and current medication lists were reconciled on the same day. In the event of an audit, you will need to provide medical record documentation that supports one of the afore mentioned requirements.

Thank you and have a great day.

Ngozi Uzokwe
PIMMS Team

--QPP Service Center Production

 

For PREV-13, can the diagnosis code of E78.2 be used to complete the measure? According to the measure documentation, E 78.00 and E78.01 is acceptable. Just wondering if there is a way to do an exception. (2/5/2018)

The diagnosis coding for PREV-13 is considered to be all-inclusive per the measure developer. If you find medical record documentation that confirms a diagnosis which meets the measure diagnosis requirement that medical record documentation can be used to support confirmation of diagnosis.

Thanks,
Deb Kaldenberg

--QPP Service Center Production

 

Regarding abstracting for M16, how do we report excluding certain medical options for Breast Feeding, pregnancy? (2/8/2018)

Thank you for calling the qpp service center. We had discussed when you are entering your reporting for on the Web Interface, you would just enter the that there are exclusions. You do not have to list what the exclusions are.

--QPP Service Center Production

 

For MH-1 we have a patient who had the diagnoses but was then unable to answer questions due to confusion. Should we list this as a denominator exclusion? The patient's ranking is 93. (2/1/2018)

Hi James,

There is no exclusion for confusion. If the patient has an active diagnosis of major depression or dysthymia during them denominator identification measurement period (12/1/2015-11/30/2016) then you would follow the abstraction steps provided in the performance flow on page 15 of the MH-1 measure specification. If the patient does not have one or more PHQ-9s administered during the denominator identification measurement period then you would code "NO" and the patient would be skipped and replaced. However, if there is a PHQ-9 > 9 then you would code "YES" and continue to report the numerator quality action.

The revised 2017 CMS Web Interface measures specifications are now available on the Resource Library page of the QPP web site at: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/We...

Thank you,
Jessica Schumacher
PIMMS Measures Team

--QPP Service Center Production

 

I have 2 patients that are in our sample for Care-1 Medication Reconciliation and both patients are on Palliative Care and/or Hospice. Do we need to submit this as a CMS approved reason for exclusion? There is not an exclusion option in the excel template.(1/31/2018)

Answer the “Patient qualified for this measure?” question by choosing “No-Other CMS approved reason”. Then in the comments, list palliative care and the effective date.

--Cana Howard

 

Circling back on this... The Comment box is blacked out when you select “No-Other CMS Approved Reason”. Should this go into the QPP Ticket box? Also is this the same approach we should be using if a patient is deceased?

I place the comment in the correct box whether it's gray or blue/white because it still shows up in the Excel upload, if you use the Excel to upload. I also placed it in the general comments that we decided not to use just in case there's a problem with the grayed-out box. Quick clarification, at the last group webinar, we agreed that no one was using the general comments so we'd keep it that way. With this situation, however, I think that it might be warranted.

--Cana Howard

 

For CARE-1, we have a patient has discharge dates that are one day apart: 01/16 and 01/17/2017. We can't look for a 30 day follow up when discharges one right after the other. How should we proceed? (1/31/2018)

Hi James,

Thank You for your question regarding CMS Web Interface Measure CARE-1: Medication Reconciliation Post-Discharge.

The performance rate for the CARE-1 measure is based on discharges, not on patients. It is possible for a patient to have more than one discharge listed in the web interface. In order to complete a patient with multiple discharges, verification of the discharge and the medication reconciliation for each discharge verified must be answered. It is possible for a single patient with two verified discharges to have one "performance met" discharge reconciliation and one "performance not met" discharge reconciliation.

The ACO is responsible for validating the inpatient discharge dates and that a visit occurred within the ACO within 30 days of the inpatient discharge date. There must be a specific discharge date noted in the medical record documentation. CMS expects organizations to make a concerted effort to obtain medical records for their assigned and sampled beneficiaries. This includes collaborating with physicians and/or other clinic staff both inside and outside the organization, as well as facilities both inside and outside the organization, with such collaboration attempts being repeated throughout the course of the data collection period, if needed. If the provider was not able to obtain the discharge date, then you would code "No" to the question "Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?", and those patients would be removed from the performance calculation.

Thank You and have a great day.

Ngozi Uzokwe
PIMMS Team

--QPP Service Center Production

 

I have the mammo report but if the patient has not returned since the mammogram there would be no documentation for “reviewed” in chart note. So my question is, IF I have the mammo report is that enough to complete the measure?(1/31/2018)

The report can be used to prove that the test was performed. The measure doesn’t require that the doctor review the results with the patient.

--Cana Howard

 

For MH-1 we have a patient who had the diagnoses but was then unable to answer questions due to confusion. Should we list this as a denominator exclusion? The patient's ranking is 93.(1/31/2018)

Hi James,

There is no exclusion for confusion. If the patient has an active diagnosis of major depression or dysthymia during them denominator identification measurement period (12/1/2015-11/30/2016) then you would follow the abstraction steps provided in the performance flow on page 15 of the MH-1 measure specification. If the patient does not have one or more PHQ-9s administered during the denominator identification measurement period then you would code "NO" and the patient would be skipped and replaced. However, if there is a PHQ-9 > 9 then you would code "YES" and continue to report the numerator quality action.

The revised 2017 CMS Web Interface measures specifications are now available on the Resource Library page of the QPP web site at: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/We...

Thank you,
Jessica Schumacher
PIMMS Measures Team

--QPP Service Center Production

 

For CARE-1, how do we answer when the patient was admitted directly into inpatient acute rehab after the inpatient discharge? Per the FAQ, rehab is considered inpatient (1/31/2018)

No answer yet.

 

For the DM-7 measure, is the following comments enough to answer "Yes"? "MiChart Labs; Pt had cartaract lens replacements on 02/01 and 03/08/2017; Per Kellogg staff, diabetic eye exam is part of cataract evaluation; Per 04/26/2017 OV, pt has no retinopathy."For the DM-7 measure, is the following comments enough to answer "Yes"? "MiChart Labs; Pt had cartaract lens replacements on 02/01 and 03/08/2017; Per Kellogg staff, diabetic eye exam is part of cataract evaluation; Per 04/26/2017 OV, pt has no retinopathy."(1/30/2018)

The eye exam must be performed by an ophthalmologist or optometrist. Nowhere on this note says that this was done, therefore it's a "no".

Thank you,
Morgan
MIPS Program Support

--QPP Service Center Production

 

We have a patient that is Autistic and has developmental delays and cannot respond to the depression screening questions. The patient is dependent on a caregiver to answer all questions. We are requesting a CMS-approved reason for exclusion for Prev-12.(1/30/2018)

Hi James,

If there is medical record documentation stating that the provider was unable to administer the depression screening due to a medical condition then you should select "DENOMINATOR EXCEPTION – MEDICAL REASON" and the patient will be removed from the measure. If there is no documentation, then you would need to code "NO" to question "Was the patient screened for depression using an age appropriate standardized tool between January 1 and December 31, 2017?" which will be a fail. This scenario is not eligible for a CMS Approved Reason request because PREV-12 offers denominator exceptions when supported with proper documentation.

Thank you,
Jessica Schumacher
PIMMS Measures Team

--QPP Service Center Production

 

POM ACO has a patient who has a “mental retardation” diagnosis and has a care giver. It was documented in the chart on 10/2017 that the care giver said the patient could not get mammogram due to her not being able to tolerate it or hold still. It is also asking for depression screening for this patient, however, I don’t believe she has the capacity to truly answer. Would we be able to get valid exclusions?(1/25/2018)

Thank you for your request for a CMS Approved Reason to skip a beneficiary included in your 2017 sample for web interface quality measure submission.

(1 of 2) The following request has been approved:
Patient(s) Rank: 216
Measure: PREV-5: Breast Cancer Screening
Reason for Request: POM ACO has a patient who has a "mental retardation" diagnosis and has a care giver. It was documented in the chart on 10/2017 that the care giver said the patient could not get mammogram due to her not being able to tolerate it or hold still. The caregiver is patient's legal guardian.

(2 of 2) The following request has been approved:
Patient(s) Rank: 606
Measure: PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Reason for Request: POM ACO has a patient who has a "mental retardation" diagnosis and has a care giver. It is also asking for depression screening for this patient, however, I don't believe she has the capacity to truly answer. Would we be able to get valid exclusion?

Please maintain this case resolution as proof that the CMS Approved Reason to Skip has been approved.

Thank you,
PIMMS Measures Team

--QPP Service Center Production

 

For PREV-9, what is the definition of “illness”? We have a case that will need a follow-up plan but the provider documented increase weight and the ability is due to dyspnea on exertion. #CS0066284(1/25/2018)

If I am understanding correctly, you are saying that the note in the medical record indicates the patient's weight has increased and patient is unable to do exercise or exert themselves due to dyspnea (shortness of breath). That alone would not be considered a denominator exception. Also, the exception only applies to Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions.
There are forms of treatment besides exercise that can be conducted as a result of a BMI outside normal limits. Please refer to Page 6 of the measure specifications for definition of a follow-up plan.

Follow-Up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. A follow-up plan may include, but is not limited to: documentation of education, referral (for example a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling.

Here is some additional guidance for the PREV-9 measure for 2017 reporting:
You would use the most recent visit in 2017 for abstraction. Then look to see if the most recent visit has a calculated BMI. If yes, the follow-up plan must be documented at that visit. If there is no follow-up plan, look may look back six months from the encounter date (which may be in 2016) to see if a calculated BMI is found/documented. Once you locate that BMI, you may answer the normal/abnormal and follow-up plan questions. The 6 month look back period applies to the BMI, and then if abnormal, a follow-up plan needs to be documented at that same encounter.

Thank you,
Angie Stevenson
PIMMS Measures Team

--QPP Service Center Production

 

For the DM-7 measure, we would like a QualityNet ticket for a blind patient. The patient didn’t need an eye exam because the patient was blind.(1/24/2018)

Thank you for your request for a CMS Approved Reason to skip a beneficiary included in your 2017 sample for web interface quality measure submission.

The following request has been approved: CS0060942
Patient(s) Rank: 351
Measure: DM-7: Diabetes: Eye Exam
Reason for Request: Patient is blind. Patient is a 63-year-old female who has been blind since birth secondary to retinopathy of prematurity

Please maintain this case resolution as proof that the CMS Approved Reason to Skip has been approved.

Thank you,
PIMMS Measures Team

--QPP Service Center Production

 

For MH-1 for the follow up it says enter the score between 0 and 4, but a patient is 20. What should we do? (1/23/2018)

Looking at the Web Interface excel template, on column AW question is "did the patient achieve remission with a follow-up PHQ-9 performed and a score less than 5 at 12 months of the initial index date?" With your score being at 20 you would want to select "no" as it is not less than 5. By selecting no that then blocks out column AY where it is asking you to enter a number between 0 and 4.

If you have further questions, please respond below and we will be happy to assist you.

Thank you,
Megan
MIPS Program Support

--QPP Service Center Production

 

Regarding IVD, TIA and CVA are considered for the IVD measure correct?(1/23/2018)

Only if the diagnosis appears on the “DenominatorCodes” worksheet (IVD Coding Document v1.1). The issue with TIA and Stroke is that it has to be embolic and not hemorrhagic, hence the reliance on codes.

--Cana Howard

 

If a practice is reporting ACI through their EHR registry, do they need an EIDM account? The practice wouldn’t need to access the qpp.cms.gov, and thus no need for an EIDM account. (1/18/2018)

Per your email, You will need to have an Enterprise Identify Management (EIDM) account and an appropriate user role associated with your organization in order to sign-in and submit data to the Quality Payment Program. An EIDM account provides eligible clinicians with a single identification that they can use across many of our CMS systems.

Approved registries will be able to log-in to the system. Third party vendors other than registries will need to request staff member access from the practice's security officer. You may want to speak with your EHR registry to find out what role you would need to have and contact you ACO as well. --Talon Telford

--QPP Service Center Production

 

Our ACO's beneficiary sample has patients with the same ranking in two different measure? These are being given in same ranking number in BMI and Tobacco?? (1/12/2018)

Hi James, It is possible and not unexpected for a given beneficiary to have the same ranking number in multiple measure. Best, Olivia

--QPP Service Center Production

 

For the PY 2017 sampled patient rank file available in the MFT, there is a column called “CEC” at the end. If a patient with a value of “Yes” in that column this patient is in the Comprehensive ESRD program, and I believe that they are supposed to be removed from the MSSP program. In our patient rank file there are 14 such patients out of the 3,578 sampled patients. Should we still abstract for these patients or not? (1/8/2018)

Thank you for your request for a CMS Approved Reason to Skip. The following request has been approved:

Reason for Request: CEC beneficiary should have been excluded from 2017 Q3 assignment.
Measure/Ranks:
1. MH-1: 127
2. CARE-1: 162
3. CARE-2: 185; IVD-2: 61; PREV-7: 194; PREV-8: 185; PREV-9: 212, PREV-10: 212, PREV-12: 177, PREV-13: 124
4. IVD-2: 392
5. DM: 444
6. CARE-1: 555
7. CARE-1: 176
8. PREV-13: 578
9. PREV-6: 558
10. PREV-13: 727
11. IVD-2: 417
12. MH-1: 501
13. DM: 432
14. PREV-5: 434
Please maintain this case resolution as proof that the CMS Approved Reason to Skip has been approved.
Best,
Olivia

--QPP Service Center Production

NOTE: I contacted via MiShare all the QROs who have the 14 CEC beneficiaries and instructed them to skip the beneficiaries and put the ticket number into the General Comments. --James

 

Follow up question: Our institution uses “Care Everywhere” where we can view documentation from visits that patients have had with providers outside of our ACO. Using CARE-1 as an example, can we use documentation of post-discharge medication reconciliation that we can view using “Care Everywhere” if it occurred at an office outside of our ACO? Or can we only use documentation by members of our ACO? (12/18/2017)

As long as you have the required patient record information available to you at the point of care, and that information meets the requirement of the measure, you may utilize it for the web interface measures.
Please let me know if this addresses your question. I will leave this ticket open until mid-day Monday in case you need further clarification.
Thank you,
Allison
QPP PIMMS Team

--QPP Service Center Production

 

For PREV-13, what happens if the patient refuses the statin prescription and their reason is not related to adverse effect, allergy or intolerance? I don't see an exclusion reason for medication refusal so am I correct in thinking that this counts against us since there would be no prescription on the chart. (12/12/2017)

If it is documented in the medical record that the patient was prescribed statin therapy during the measurement period but refused the prescription, the intent of the measure has been met.

Thank you,
Angie Stevenson
PIMMS Measures Team

--QPP Service Center Production

 

Follow-up: So then is it correct to say that the provider MUST formally prescribe the statin medication in order for the ACO to receive credit for this measure? In other words, even if the provider knows ahead of time that the patient will refuse to take the medication, the provider must still go through the motions of formally prescribing the medication before the patient's refusal is considered to be disqualifying? (12/20/2017)

If it is documented in the medical record that the clinician advised the patient they wanted them to begin statin therapy and the patient stated refusal of the prescription during the measurement period, the intent of the measure has been met.

Thank you,
Angie Stevenson
PIMMS Measures Team

--QPP Service Center Production

 

For PREV-9, is the 6 month look-back calculated using the most recent BMI and NOT the most recent visit. How is the date of the most recent BMI used? (12/12/2017)

If a BMI was not documented during the most recent encounter, then you can look back through the medical records 6 months (<7 months) to see if a BMI was documented. If there is more than one BMI in that 6 month time frame then you must use the most recent BMI.

Thank you,
Jessica Schumacher
PIMMS Measures Team

--QPP Service Center Production

 

If a beneficiary has an SNP code that will exclude them from the measure, what supporting documentation would be needed to pass an audit? (12/5/2017)

You may select the Denominator Exclusion during the denominator confirmation process if medical record documentation indicates the patient is 65 or older during the measurement period and in Institutional Special Needs Plan (SNP) or resides in any of the following types of Long Term Care:

  • (POS32) Nursing Facility: A long-term facility which primarily provides residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than individuals with intellectual disabilities.
  • (POS 33) Custodial Care Facility: A facility which provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
  • (POS 34) Hospice: A facility, other than a patient's home, in which palliative and supportive care for terminally ill patients and their families are provided.
  • (POS 54) Intermediate Care Facility/Intellectuals with Disabilities A facility which primarily provides health-related care and services above the level of custodial care to individuals but does not provide the level of care or treatment available in a hospital or SNF.

Please note that patients in POS 31 Skilled Nursing Facility (short term) are not excluded from the measure. Also worth noting is if the patient is considered to be in hospice they should be removed at the patient confirmation level and not the measure level as this is a submission method wide requirement.

When submitting data through the CMS Web Interface, the expectation is that medical record documentation is available that supports the action reported in the Web Interface.

Thank you,
Angie Stevenson
PIMMS Measures Team

--QPP Service Center Production

 

For the new CMS Web Interface Excel Template, will the Clinic ID and Provider Name 1, 2, 3 fields be populated when we download it with our patient sample? (11/29/2017)

The Web Interface templates are blank and only contain dummy patient data. The templates are simply examples for users to get a snapshot of how the files will look ahead of time. You can refer to the User Guide for direction as to how to complete the templates, but the templates themselves are just for show.

Once the submission period is open, you will be given new files which contain your beneficiary data. Unfortunately we don't have a date set for when your files will be available. Until then, the Web Interface Excel template is just for you to get an idea beforehand.

--QPP Service Center Production

 

Our ACO is a track 1 and for several reasons their EIDM Group and Role are different: PQRS Provider/Web Interface Submitter or PV Provider/Group Representative. Do all our abstractors have to have the same group and role? (11/27/2017)

They are not all required to have the same roles. Please refer to the EIDM User Guide for the definitions of each role available for the Quality Payment Program. You can locate the EIDM User Guide on the CMS website at https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/Enterprise-Identity-Data-Management-EIDM-User-Guide.pdf

--QPP Service Center Production

 

Do you have to change your EIDM password every 45 days? (11/3/2017)

If you change your password, the new password will expire in 60 days and needs to be changed prior to expiration. This is done by logging into your EIDM account and clicking the "My Profile" tab. The URL for EIDM is portal.cms.gov

--QPP Service Center Production