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Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
TABLE 52: Individual Quality Cross-Cutting Measures for the PQRS to Be Available for
Satisfactory Reporting Via Claims, Registry, and EHR Beginning in 2015
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Tobacco Use and Help with Quitting
Among Adolescents: The percentage of
adolescents 12 to 20 years of age with a
primary care visit during the
measurement year for whom tobacco use
status was documented and received help
with quitting if identified as a tobacco
user
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Hepatitis C: One-Time Screening for
Hepatitis C Virus (HCV) for Patients
at Risk: Percentage of patients aged 18
years and older with one or more of the
following: a history of injection drug use,
receipt of a blood transfusion prior to
1992, receiving maintenance
hemodialysis OR birthdate in the years
1945-1965 who received a one-time
screening for HCV infection
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NCIQM
X
AGA/
AASLD/
AMAPCPI
X
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Medication Reconciliation: Percentage
of patients aged 18 years and older
discharged from any inpatient facility (for
example, hospital, skilled nursing facility,
or rehabilitation facility) and seen within
30 days following discharge in the office
by the physician, prescribing practitioner,
registered nurse, or clinical pharmacist
providing on-going care who had a
reconciliation of the discharge
medications with the current medication
list in the outpatient medical record
documented
NCQA/
AMAPCPI
X
X
X
This measure is reported as two rates
stratified by age group:
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Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
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Reporting Age Criteria 1: 18-64 years of
age
Reporting Age Criteria 2: 65 years and
older.
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Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Preventive Care and Screening:
Influenza Immunization: Percentage of
patients aged 6 months and older seen for
a visit between October 1 and March 31
who received an influenza immunization
OR who reported previous receipt of an
influenza immunization
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Pneumonia Vaccination Status for
Older Adults: Percentage of patients 65
years of age and older who have ever
received a pneumococcal vaccine
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Communi
cation and
Care
Coordinati
on
Commenters supported the inclusion of
this measure as cross cutting "due to its
focus on critical care coordination
transitions between hospitals and
ambulatory care providers." As such,
CMS is finalizing its proposal to make
this measure reportable as a cross-cutting
measure for 2015 PQRS. We note that
while the proposed rule limited the
applicability of this measure to patients
65 years and older, the range of this
mesaure was changed to include patients
18-64 years of age by the measure
steward. This measure update is endorsed
byNQF.
Care Plan: Percentage of patients aged
65 years and older who have an advance
care plan or surrogate decision maker
documented in the medical record or
documentation in the medical record that
an advance care plan was discussed but
the patient did not wish or was not able to
name a surrogate decision maker or
provide an advance care plan
67803
Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
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Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Preventive Care and Screening: Body
Mass Index (BMI) Screening and
Follow-Up Plan: Percentage of patients
aged 18 years and older with a BMI
documented during the current encounter
or during the previous six months AND
with a BMI outside of normal parameters,
a follow-up plan is documented during
the encounter or during the previous six
months of the current encounter
Normal Parameters: Age 65 years and
older BMI 2:23 and< 30 kg/m2; Age 1864 years BMI 2: 18.5 and< 25 kg/m2
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Documentation of Current Medications
in the Medical Record: 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
Patient
Safety
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Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Pain Assessment and Follow-Up:
Percentage of visits for patients aged 18
years and older with documentation of a
pain assessment using a standardized
tool( s) on each visit AND documentation
of a follow-up plan when pain is present
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67804
Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
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Preventive Care and Screening:
Screening for Clinical Depression and
Follow-Up Plan: Percentage of patients
aged 12 years and older screened for
clinical depression on the date of the
encounter using an age appropriate
standardized depression screening tool
AND if positive, a follow-up plan is
documented on the date ofthe positive
screen
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Functional Outcome Assessment:
Percentage of visits for patients aged 18
years and older with documentation of a
current functional outcome assessment
using a standardized functional outcome
assessment tool on the date of encounter
AND documentation of a care plan based
on identified functional outcome
deficiencies on the date ofthe identified
deficiencies
CMS/QIP
X
X
CMS/QIP
X
X
No comments were received regarding
this measure being classified as crosscutting. CMS is finalizing its proposal to
make this measure reportable as a crosscutting measure for 2015 PQRS.
Preventive Care and Screening:
Tobacco Use: Screening and Cessation
Intervention: Percentage of patients aged
18 years and older who were screened for
tobacco use one or more times within 24
months AND who received cessation
counseling intervention if identified as a
tobacco user
AMAPCPI
X
X
X
X
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
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No comments were received regarding
this measure being classified as crosscutting. CMS is fmalizing its proposal to
make this measure reportable as a crosscutting measure for 2015 PQRS.
67805
Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
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Controlling High Blood Pressure:
Percentage of patients 18-85 years of age
who had a diagnosis of hypertension and
whose blood pressure was adequately
controlled (<140/90 mmHg) during the
measurement period
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Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS. This measure was part of the
cardiovascular prevention and ischemic
vascular disease measures group.
Therefore, the details and rationale
regarding the changes we are making to
this measure can be found in our
discussion of the cardiovascular
prevention and ischemic vascular disease
measures group in section III.K.5.d ofthis
final rule.
Childhood Immunization Status:
Percentage of children 2 years of age who
had four diphtheria, tetanus and acellular
pertussis (DTaP); three polio (IPV), one
measles, mumps and rubella (MMR);
three H influenza type B (HiB); three
hepatitis B (Hep B); one chicken pox
(VZV); four pneumococcal conjugate
(PCV); one hepatitis A (Hep A); two or
three rotavirus (RV); and two influenza
(flu) vaccines by their second birthday
NCQA
X
NCQA
X
X
X
X
ACO
MU2
Million
Hearts
MU2
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Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
67806
Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
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Preventive Care and Screening:
Screening for High Blood Pressure and
Follow-Up Documented: Percentage of
patients aged 18 years and older seen
during the reporting period who were
screened for high blood pressure (BP)
AND a recommended follow-up plan is
documented based on the current blood
pressure reading as indicated
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Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
Falls: Screening for Fall Risk:
Percentage of patients 65 years of age and
older who were screened for future fall
risk at least once during the measurement
period
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Patient
Safety
N/
A
Person
and
Caregiver
Experienc
eand
Outcomes
Commenters agreed this measure was
appropriately classified as cross-cutting.
For this reason, CMS is finalizing its
proposal to make this measure reportable
as a cross-cutting measure for 2015
PQRS.
CAHPS for PQRS Clinician/Group
Survey:
• Getting timely care, appointments, and
information;
• How well providers Communicate;
• Patient's Rating of Provider;
• Access to Specialists;
• Health Promotion & Education;
• Shared Decision Making;
• Health Status/Functional Status;
• Courteous and Helpful Office Staff;
• Care Coordination;
• Between Visit Communication;
• Helping Your to Take Medication as
Directed; and
• Stewardship of Patient Resources
NCQA
AHRQ
X
ACO
MU2
ACO
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No comments were received regarding
this measure being classified as crosscutting. CMS is finalizing its proposal to
make this measure reportable as a crosscutting measure for 2015 PQRS.
Federal Register / Vol. 79, No. 219 / Thursday, November 13, 2014 / Rules and Regulations
Table 22 in the CY 2015 PFS
proposed rule (79 FR 40410) contained
the additional measures we proposed to
include in the PQRS measure set for CY
2015 and beyond. In Table 53, we
VerDate Sep<11>2014
20:15 Nov 12, 2014
Jkt 235001
provide our response to the comments
we received on these measures as well
as our final decisions on these proposed
measures. We have also indicated the
PQRS reporting mechanism or
mechanisms through which each
measure could be submitted. As stated
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above, please note that the following
tables may also contain discussions of
comments we received related to
proposed changes to the measures
included in the quality performance
standard under the Shared Savings
Program.
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c. New PQRS Measures Available for
Reporting for 2015 and Beyond
67807