Measure Description:  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:  All patients aged 18 years and older before the start of the measurement period with at least one eligible encounter during the measurement period

Denominator: Equals Initial Population

Numerator: Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated if the blood pressure is pre-hypertensive or hypertensive

Denominator Exclusions: Patient has an active diagnosis of hypertension

Denominator Exceptions:

• Patient Reason(s):
  • Patient refuses to participate (either BP measurement or follow-up) OR;
• Medical Reason(s):
  • 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. This may include but is not limited to severely elevated BP when immediate medical treatment is indicated. OR;
  • Marking that a patient refused any of the following will include the patient as an exception’: Intervention order, medication order, laboratory test, or diagnostic study.

1.  Patient must be 18 years or older before the start of the measurement period

• Patient must have a code related to BP Screening Encounter Codes
  • Most commonly used codes
    • 92002, 92004, 92012, 92014

2.  Patient must have a high blood pressure reading

• 4 scenarios can meet this requirement
  1. Systolic BP < 120 and Diastolic BP < 80
  2. Systolic BP >/= 120 and < 140 and Diastolic BP < 90
  3. Within the last year there hasn't been an out of range BP, and Systolic BP >/= 140 or Diastolic BP is >/= 90
  4. Within the last year there has been an out of range BP of Systolic BP >/= 140 or Diastolic BP >/= 90 AND the most recent visit has a Systolic BP >/=140 and a Diastolic BP >/= 90

3.  Patient must have a recommended follow up plan documented

• Create a referral order
• Under referral type, use "Referral to a doctor"

High Priority Measure

Measure Description:  Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Initial Patient Population:  Number of patients, regardless of age, who were referred by one provider to another provider, and who had a visit during the measurement period

Denominator: Equals Initial Population

Numerator: Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred

Denominator Exclusions: None

Denominator Exceptions:  None

1.  Patient must have a code related to Ophthalmological Services (others are available, attached above)

• Most commonly used codes 
  • 92002, 92004, 92012, 92014

2.  Create a referral order and send to provider

3,  Once confirmed the order is received, click the "Close" button on the orders tab

Measure Description:  Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known 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 Population

Numerator:  Eligible professional attests to documenting, updating or reviewing the patient's current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosages, frequency and route of administration 

Denominator Exclusions: None

Denominator Exceptions:  

Medical Reason:

• 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

1.  Patient must have a code related to the Medications Encounter Code Set

• Most commonly used codes
  • 92002, 92004, 92012, 92014

2.  User must check off "Complete List of Medications"

Measure Description:  Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

Initial Patient Population:  All patients 18 and older on the date of the encounter with at least one eligible encounter during the measurement period

Denominator: Equals Initial Population

Numerator: Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

Denominator Exclusions: 

• Patients who are pregnant 
• Patients receiving palliative care
• Patients who refuse measurement of height and/or weight or refuse follow-up

Denominator Exceptions:

Patients with a documented Medical Reason:

• Elderly Patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples:
  • Illness or physical disability
  • Mental illness, dementia, confusion
  • Nutritional deficiency, such as Vitamin/mineral deficiency
• Patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status

1.  Patient must be 18 or older on date of encounter

2.  Patient must have a code related to the BMI Encounter Code Set

• Attached at the top of this section

3.  And one of the following:

1. Within the last six months, the patient had a reading of >/= 18.5 kg/m2 and < 25 kg/m2
2. Overweight
   1. Diagnosis related to Overweight (example, Z71.3) AND
   2. Referral sent (see above attachments for referral types) OR
   3. A medication related to overweight (attached above) AND
   4. A BMI reading >/= 25 kg/m2
3. Underweight
   1. Diagnosis related to Underweight (example, R63.6) AND
   2. Referral sent (see above attachments for referral types) OR
   3. A medication related to Underweight (attached above) AND
   4. A BMI reading >/= 18 kg/m2

Measure Description:  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 Population

Numerator: Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%

Denominator Exclusions: Patients who were in hospice care during the measurement year

Denominator Exceptions: None

1.  Patient must have a diagnosis of Diabetes

2.  Patient must be between 18 and 75 years of age

3.  Must have an encounter code related to: (attached above for reference)

• Office Visit
• Face to Face Interaction
• Preventive Care Services - Established Office Visit, 18 and Up
• Preventive Care Services-Initial Office Visit, 18 and Up
• Home Healthcare Services
• Annual Wellness Visit

4.  Patient must have a HbA1c reading >9%

Measure Description:  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 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

Denominator Exclusions: Patients who were in hospice care during the measurement year.

Denominator Exceptions: None

1.  Patient must have a diagnosis related to diabetes (see attached document above)

2.  Must be between 18 and 75 years of age

3.  Must have an appropriate encounter code

• Most commonly used codes
  • 92002, 92004, 92012, 92014

4.  Any of the following:

• Patient must have a green check mark or a red "X" in the Physical Exam for "Retina/Choroid" OR

• Patient must have dilation check off in the physical exam OR

• Patient must have one of the following Optomap, Retinal imaging OCT, GDX performed under Screening Procedures OR
• Special Tests/Procedures - 92225, 92226, 92250, 92134

Measure Description:  Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:

• Population 1: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
• Population 2: Percentage of patients aged 18 years and older who were screened for tobacco use and identified as a tobacco user who received tobacco cessation intervention
• Population 3: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation 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:

Population 1: Equals Initial Population

Population 2: Equals Initial Population who were screened for tobacco use and identified as a tobacco user

Population 3: Equals Initial Population

Numerator:

Population 1: Patients who were screened for tobacco use at least once within 24 months

Population 2: Patients who received tobacco cessation intervention

Population 3: Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Denominator Exclusions: None

Denominator Exceptions: 

Population 1: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)

Population 2: Documentation of medical reason(s) for not providing tobacco cessation intervention (eg, limited life expectancy, other medical reason)

Population 3: Documentation of medical reason(s) for not screening for tobacco use OR for not providing tobacco cessation intervention for patients identified as tobacco users (eg, limited life expectancy, other medical reason)

1.  Must have an appropriate encounter code

• Most commonly used codes
  • 92002, 92004, 92012, 92014

2.  Must have the following selected based on Population:

• Population 1:
• Never used tobacco under PFSH

• Population 2:
• Must have Yes selected under "Has Tobacco History" in PFSH  

• Population 3:
• Must have Yes selected under "Has Tobacco History" in PFSH, AND
• Either "Intermediate (less than 10 min)" or "Intense (more than 10 min)" selected under Counseling PFSH

High Priority Measure

Measure Description:  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 Population who had a dilated macular or fundus exam performed

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

Denominator Exclusions: None

Denominator Exceptions: 

• Documentation of medical reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes
• Documentation of patient reason(s) for not communicating the findings of the dilated macular or fundus exam to the physician who manages the ongoing care of the patient with diabetes

1.  Patient must be 18 years of age or older

2.  Have a diagnosis of Diabetic Retinopathy (attached above)

3.  Must have an appropriate encounter code

• Most commonly used codes
  • 92002, 92004, 92012, 92014

4.  Patient must have either "Dilation" or "Default Dilated" checked off within the Physical Exam AND

5.  Patient must have a "Retina/Choroid" finding documented on the Physical Exam

6.  And one of the following:

• Check off "Findings communicated to the Primary Care Provider"
• User prints the exam
• User creates a Professional CCD

Measure Description:  Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma (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

Denominator: Equals Initial Population

Numerator: Patients who have an optic nerve head evaluation during one or more office visits within 12 months

Denominator Exclusions: None

Denominator Exceptions: Documentation of medical reason(s) for not performing an optic nerve head evaluation

• Patient will not be included in the Numerator if "Unable to Perform Exam for Medical or Patient Reasons" is selected in the CD Ratio section of the Exam

1.  Patient must be 18 years or older

2.  Must have an appropriate encounter code

• Most commonly used codes
  • 92002, 92004, 92012, 92014

3.  Any one of the following:

• Patient have a left or right vertical ratio documented

• Patient has "X" selected in the Physical Exam for the "Optic Nerve/Visual Pathway"
• X/Check for Glaucoma in PE

• Screening Procedures - Optomap, Retinal Imaging, OCT, GDX

• Special Tests/Procedures - 92225, 92226, 92250, 92134

Measure Description:  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

Initial Patient Population:  All patients aged 18 years and older with a diagnosis of diabetic retinopathy

Denominator: Equals Initial Population

Numerator: Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmHg and diastolic blood pressure < 90 mmHg) during the measurement period

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.

• Exclude patients who were in hospice care during the measurement year.

Denominator Exceptions: None

1.  Patient must be between 18 and 85 years of age

2.  Patient must have a diagnosis of essential hypertension within 6 months of the start of the measurement period

3.  Must have an encounter code related to: (attached above for reference)

• Office Visit
• Face to Face Interaction
• Preventive Care Services - Established Office Visit, 18 and Up
• Preventive Care Services-Initial Office Visit, 18 and Up
• Home Healthcare Services
• Annual Wellness Visit

4.  Patient has a Diastolic Blood Pressure result <90 mmHg and systolic <140 mmHg