Download Medicare part B has developed the PQRS

Medicare part B has developed the PQRS (Physician Quality Reporting System): a list of 300+ quality measures that address various aspects of Pt care, including prevention, chronic
disease management, acute episode care management, procedure, related care, resource utilization, and care coordination.
FOR OFFICE: ____POP-up “PQRS DONE …”
We have selected 10 measures. Please help us by answering the following questions.
______ Mammo set REMINDER
Last Name: ______________________________________First Name:
DOB:
. ______ BMI and ____plan on prgnote needed?
_____ A1c/glucose _____for DM eye/foot ref?
1. Current Medications in the Medical Record #130
Current Medications –presently taking including all prescriptions, over-the-counters (OTC), herbals and
vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route.
1A. ___Confirm the meds, OTC, vitamin, etc on file is current. (PQRS=G8427)
1B. ___Current Meds not Documented, Pt not Eligible: urgent medical situation where time is of the essence /delay
treatment would jeopardize the Pt’s health status. (PQRS=G8430)
1C. ___NOT Confirm the medications on file is current. Reason not given (PQRS=G8428)
1D. ___Additional information: ____________________________________
2. Influenza immunization measure #110
Summary of step. 1) Write BMI. 2) find last A1c
/Glucose result to. 3) Inform pt if have not falling
within 12 months, pt may skip question 9 and 10.
4) Pt may skip 11 if pt is not diabetes. 5) ask pt write
reason if DONOT want mammogram reminder.
6) Once pt done, review all answers. 7) write on
progress note any “PLAN” needed, see FALL 10C,
10D… DM=diabetes referral eye, foot, BMI plan …
______ Plan on prg note
______ Addendum
Previous 2014-15Flu season from Aug 2014 - March 2015 and Current 2015-2016 flu season from Aug 2015 - March 2016
2A. ___Received Influenza during for previous 2014-2015 or current 2015-2016 flu season (PQRS=G8482)
2B. ___NOT Received Influenza during previous 2014-2015 or current 2015-2016 flu reasons: allergy or other medical reasons (PQRS=G8483)
2C. ___NOT Received Influenza during previous 2014-2015 or current 2015-2016 flu reasons: Pt declined or other Pt reasons (PQRS=G8483)
2D. ___NOT Received Influenza during previous 2014-2015 or current 2015-2016 flu reasons: vaccine not available or other system reasons (G8483)
2E. ___NOT Received Influenza during previous 2014-2015 or current 2015-2016 flu reasons: not given. (PQRS=G8484)
3. Pneumonia vaccination status measure #111
65+ age: Pneumonia is a common cause of illness and death in the elderly and persons with certain underlying conditions such as heart failure, diabetes, cystic fibrosis, asthma, sickle cell
anemia, or chronic obstructive pulmonary disease.
3A. ___Received pneumonia vaccination (PQRS=4040F)
3B. ___NOT ever received pneumonia vaccination (PQRS=4040F with 8P)
4. Advance care plan or surrogate decision maker #47
65+ age: It is essential that the Pt’s wishes regarding medical treatment be established as much as possible prior to incapacity.
Advance directives are designed to respect Pt’s autonomy and determine his/her wishes about future life-sustaining medical treatment if unable to indicate wishes.
4A. ___Name of surrogate decision maker and relationship to Pt. (PQRS=1123F) ________________
4B. ___St Michael has a copy of Living Will, Advance Directive or other similar signed form. (PQRS=1123F)
4C. ___Will provide St Michael a copy of Living Will, Advance Directive or other similar signed form. (PQRS=1123F)
4D. ___ Do NOT wish to discuss advance care planning reasons: not given (PQRS=1123F with 8P)
4E. ___Do NOT wish to discuss advance care planning reasons: cultural and/or spiritual beliefs (PQRS=1124F)
4F. ___Do NOT wish to give name of surrogate decision maker, but have document advance care below (PQRS=1124F)
4G. ___TYPE your advance care wishes here. Key interventions and treatment decisions to include in advance directives are: resuscitation procedures, mechanical respiration,
chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood products, transfusions, and intentional deep sedation. ____________________________________
5. Breast cancer screening measure #112
Women 50 - 74 age: Breast cancer is one of the most common types of cancers, accounting for a quarter of all new cancer diagnoses for women in the U.S.
5A. ___No mammograms within 27 months prior to office-visit for medical reason: ie. mastectomy (PQRS=3014F with 1P)
5B. ___No mammograms within 27 months prior to office-visit reason: not given (PQRS=3014F with 8P)
5C. ___Had a mammograms within 27 months prior to office-visit and result was normal (PQRS=3014F)
5D. ___Had a mammograms within 27 months prior to office-visit and result was abnormal (PQRS=3014F)
5E. ___ Additional notes about mammograms: ____________________________________
6. Reminder for screening mammograms measure #225
40+age: Although screening mammograms can reduce breast cancer mortality by 20-35% in women aged 40 years and older, recent evidence shows that only 72% of women are receiving
mammograms based on current guideline recommendations. PQRS= (DX=V76.11, V76.12), (CPT=77057, G0202)
6A. last mammogram date, _____________ PLEASE provide reason you DO NOT want a mammogram reminder call. ______________________________________________________
{For office staff: Enter "Set a REMINDER" 12months fr last mammo. Staff initial done: ______________ }
7. Colorectal cancer screening #113
50 - 75 age: Screening for colorectal cancer is extremely important as there are no signs or symptoms of the cancer in the early stages. If the disease is caught in its earliest stages, it has a
five-year survival rate of 91%; however, the disease is often not caught this early. Colorectal cancer is the third leading cause of cancer death in the United States (American Cancer Society
2010). Appropriate screenings are defined by any one of the following criteria: 1) Fecal occult blood test. 2) Flexible sigmoidoscopy. 3) Colonoscopy.
7A. ___Done Fecal occult blood test within 2015 (annual) and result was normal (PQRS=3017F)
7B. ___Done Flexible sigmoidoscopy during the 2012-2015 (4 years) and result was normal (PQRS=3017F)
7C. ___Done Colonoscopy during the 2007-2015 (9years) and result was normal (PQRS=3017F)
7D. ___No colorectal cancer screening reasons: diagnosis of colorectal cancer or total colectomy. (PQRS=3017F with 1P)
7E. ___No colorectal cancer screening reasons: not given. (PQRS=3017F with 8P)
8. Fall Assessment for all Pts aged 65 years and older #154
Falls are among the most common and serious problems facing elderly persons. Falling is associated with considerable mortality, morbidity, reduced functioning and premature nursing
home admissions from the community.
Definitions: Fall – A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden
onset of paralysis, epileptic seizure, or overwhelming external force.
Few Recommendation to avoid falls.
 Assess home for raised doorway thresholds
Remove clutter, loose carpet, unsecured floor coverings
 Always maintain a clean dry floor
 No electrical cords in walk ways
 Maintenance of assistive devices
 Handrails in hallways
 Install grab bars in the bathroom
 Use non-skid mats inside and outside of shower/tub/toilet
 Use of appropriate bathing aides/chair
 Store household items on lower shelves so that you can access them easily
 Use reaching devices to access things that are higher than you can reach
 Wear low heeled, comfortable shoes that fit well
 Have night lights installed
 Keep home well lit
 Always make sure to sit up on the edge of the bed and get use to light before attempting
to walk
History of falls:
8A. ___Do not wish to give history of falls. NO fall assessment done. SKIP question 9 and 10. (PQRS = 1101F with 8P, 3288P with 8P)
8B. ___Had NO falls in the past 12 months. NO fall assessment done. SKIP question 9 and 10. (PQRS = 1101F, 3288P with 1P)
8C. ___Had 1 falls WITHOUT injury in the past 12 months. NO fall assessment done. SKIP question 9 and 10. (PQRS = 1101F, 3288P with 1P)
8D. ___Had any fall WITH INJURY in the past 12 months. Continue to fall assessment. (PQRS = 1100F, see 3288F ___).
8E. ___Have 2 or more falls in the past 12 months. Continue with fall assessment. (PQRS = 1100F, see 3288F ___).
For medical reasons - Risk of fall assessment questionnaire NOT completed.
8F. ___Pt is not ambulatory (PQRS=3288F with 1P)
8G. ___ Pt is bed ridden (PQRS=3288F with 1P)
8H. ___Pt is immobile (PQRS=3288F with 1P)
8i. ___ Pt is confined to chair (PQRS=3288F with 1P)
8J. ___Pt is wheelchair bound (PQRS=3288F with 1P)
8K. ___Pt is dependent on helper pushing wheelchair (PQRS=3288F with 1P)
8L. ___Pt is independent in wheelchair or minimal help in wheelchair (PQRS=3288F with 1P)
SKIP question 9 and 10.
For non-medical reasons - Risk of fall assessment questionnaire NOT completed.
8M. ___ Pt has fallen but wish not to complete the Risk of fall assessment: reason not given. SKIP question 9 and 10. (PQRS=3288F with 8P)
9. Risk of fall assessment questionnaire **** Had NO falls in the past 12 months. NO fall assessment done. SKIP question 9 and 10.
Risk Assessment – Comprised of balance/gait AND one or more of the following: postural
blood pressure, vision, home fall hazards, and documentation on whether medications are a
contributing factor or not to falls within the past 12 months. Choose all that apply to the
following "Morse" Risk Assessment for Falls
History of falling within the last 3 months:
9A. ___No (point=0)
9B. ___Yes (point=25)
Mental status (Pt’s own assessment of ability to walk):
“Are you able to go the bathroom alone or do you need assistance?”
If the Pt’s reply judging his or her own ability is consistent with the ambulatory order
on the Kardex®, the Pt is rated as “normal” and scored 0. If the Pt’s response is not
consistent with the nursing orders or if the Pt’s response is unrealistic, then the Pt is
considered to overestimate his or her own abilities and to be forgetful of limitations
and scored as 15.
Gait (walking characteristics / abnormality):
A normal gait is characterized by the Pt walking with head erect, arms swinging freely at the
side, and striding without hesitant. This gait scores 0. With a weak gait (score as 10), the Pt is
stooped but is able to lift the head while walking without losing balance. Steps are short and
the Pt may shuffle. With an impaired gait (score 20), the Pt may have difficulty rising from the
chair, attempting to get up by pushing on the arms of the chair/or by bouncing (i.e., by using
several attempts to rise). The Pt’s head is down, and he or she watches the ground. Because
the Pt’s balance is poor, the Pt grasps onto the furniture, a support person, or a walking aid
for support and cannot walk without this assistance. A limp is also considered a walking
abnormality. A limp may be permanent or temporary.
9i. ___oriented to own ability (point = 0)
9J. ___overestimates/ forgets limit (point = 15)
9C. ___Normal gait: walk with head erect, arm swing freely at the side (point = 0)
9D. ___Gait: bedrest and/or wheel chair (point = 0)
9E. ___Gait weak: stooped, short steps, may shuffle, use furniture as a guide (point = 10)
9F. ___Impaired gait: difficulty rising from chair; head down, short -shuffling gait (point = 20)
9G. ___Impaired gait: walk with assistant, grab furniture or whatever available (point = 20)
9H. ___ impaired gait: wheelchair (point = 20)
Secondary diagnosis (of any kind listed in medical chart)
9K. ___No (point = 0)
9L. ___Yes (point = 15)
Ambulatory aid (used during gait)
9M. ___No, bedrest/ nurse assistance/ wheel chair (point = 0)
9N. ___Yes, use crutches/ cane/ walker (point = 15)
9O. ___Yes, use furniture for support (point = 20)
Intravenous therapy / saline lock (infusion of liquid substances directly into a vein):
9P. ___No, do not have IV, not attach to equipment (point = 0)
9Q. ___Yes (point = 20)
9U. Total score. _____________ 00 - 24 points = NO Risk; 25 - 50 points = Moderate Risk. ; 51 or above = HIGH RISK.
10. Plan of Care for fall #155 – Must include: 1) consideration of vitamin D supplementation AND 2) balance, strength, and gait training.
Consideration of Vitamin D Supplementation – Vitamin D promotes calcium absorption. Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Together with calcium,
vitamin D also helps protect older adults from osteoporosis.
Balance, Strength, and Gait Training – Gait training helps strengthen muscles and joints, improves balance, improves posture, develops muscle memory, builds endurance, and retrains the
legs for repetitive motion.
10A. ___ Receive and understand the value of Vitamin D Supplement.
10B. ___Plan of Care not Documented for Medical Reasons: ie, Pt is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent wheelchair. (0518F with 1P)
10C. ___Want referral to an exercise program, which goal is to increase: balance, strength, gait/walking (PQRS = 0518F)
10D. ___Want referral to an physical therapy, which goal is to increase: balance, strength, gait/walking (PQRS = 0518F)
10E. ___Plan of Care not Documented, Reason not given (PQRS = 0518F with 8P)
11. Diabetes Care (if you have been diagnosed with Diabetes only) *****Skip question 11 if you have not been diagnosis with diabetes.
Diabetes A1c Assessment #1
Diabetes: Eye Exam #117
11a. ___ During 2015, hemoglobin A1c level > 9.0% (PQRS = 3046F)
11g. ___ Had a retinal or dilated eye exam (PQRS = 2022F)
11b. ___ Most recent hemoglobin A1c level < 7.0 (PQRS = 3044F)
11h ___ Low risk for retinopathy. No evidence of retinopathy in the prior year. (3072F)
11c. ___ Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0% (PQRS = 3045F)
11i. ___ Had seven standard field stereoscopic photos (PQRS = 2024F)
11d. ___ NO recent A1c in 12 months. (PQRS = 3046F with 8P). Need A1c blood work ASAP. ***
11j. ___ Had eye imaging validated to match diagnosis from seven standard field
Diabetes: Foot Exam #163
stereoscopic photos (PQRS = 2026F)
11e. ___ Foot examination performed - includes examination through visual inspection, sensory
11k. ___ Dilated eye exam was not performed, reason not given. (PQRS = 2022F or
exam with monofilament, and pulse exam. (PQRS = G9226)
2024F or 2026F with 8P)
11f. ___ Foot exam was not performed, reason not given (PQRS = G9225)
12. For OFFICE STAFF: Body Mass Index (BMI) Screening and follow-up plan #118
Age 18 -- 64 years BMI >= 18.5 and < 25 kg/m2 and Age 65 years & older BMI >= 23 and < 30 kg/m2
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: 1) Documentation of
education. 2) Referral (eg, a registered dietitian/nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon)
3) Pharmacological interventions. 4) Dietary supplements. 5) Exercise counseling. 6) Nutrition counseling
Not Eligible for BMI Calculation or Follow-Up Plan --- A patient is not eligible if one or more of the following reasons are documented: 1) Patient is receiving palliative care. 2) Patient is
pregnant. 3) Patient refuses BMI measurement (refuses height and/or weight) 4) Any other reason documented in the medical record by the provider why BMI measurement was not
appropriate. 5) 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
12a. ___ BMI _________ is within normal parameters and no follow-up plan is required (PQRS = G8420)
12b. ___ BMI _________ is above normal parameters and follow-up plan. ___*** (PQRS = G8417)
12c. ___ BMI_________ is below normal parameters and follow-up plan. ___ *** (PQRS = G8418)
12d. ___ BMI _________not documented, documentation the patient is not eligible for BMI calculation (PQRS = G8422)
12e. ___ BMI _________ is outside of normal limits, follow-up plan is not documented, documentation the patient is not eligible (PQRS = G8938)
12f. ___ BMI_________ not documented and no reason is given (PQRS = G8421)
12g. ___ BMI _________is outside normal parameters, no follow-up plan documented, no reason given (PQRS = G8419)
Patient Signature: ______________________________ Date:_____________
FOR OFFICE: plan on prgnote? & addendum done staff initial ______