CMS Measure ID: #283
Collection Type: CQM
Reporting Frequency: Once per patient per year
Outcome: No
High Priority: No
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
Instructions
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of dementia seen during the performance period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
Measure Submission Type:
The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management in the last 12 months
2022 Benchmarks (from 2020 CMS data)
Registry
Topped out: Yes
Capped at 7: Yes
Minimum: 0 – 93.94
Decile 3: 93.95 – 99.85
Decile 4: 99.86 – 99.99
Decile 10: 100 – 100
Denominator
All patients with dementia
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
All patients regardless of age
AND
Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, F01.50, F01.51, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.81, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.91, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F05, F10.27, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94
AND
Patient encounter during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 96116, 96127, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99242*, 99243*, 99244*, 99245*, 99252*, 99253*, 99254*, 99255*, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, 99487, 99490, 99491, 99497
Numerator
Patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression in the last 12 months and for whom, if screening was positive, there was also documentation of recommendations for management in the last 12 months
Definition:
Behavioral and Psychiatric Symptoms Screening – Screening is defined as using a validated instrument or directly examining the patient or knowledgeable informant to determine the presence or absence of symptoms from three domains: Activity disturbances, mood disturbances (including depression), and thought and perceptional disturbances. The following validated instruments can be used to meet the measure:
- Dementia Signs and Symptoms (DSS) Scale
- Neuropsychiatric Inventory (NPI)
- Minimum Data Set (MDS) (suggested for nursing home only).
Numerator Instructions:
Symptoms Screening for at least one symptom each for three domains of behavioral and psychiatric symptoms, including depression is defined as using a validated instrument or directly examining the patient or knowledgeable informant to determine the presence or absence of symptoms from three domains: activity disturbances, mood disturbances (including depression), and thought and perceptional disturbances. The following is a non-exhaustive list of symptoms falling into each of the three requisite domains pertinent to this measure:
Activity disturbances (To meet measure, patient or knowledgeable informant must be screened for at least one symptom from this list):
o Agitation
o Wandering
o Purposeless hyperactivity
o Verbal or physical aggressiveness
o Resisting care
o Apathy
o Impulsiveness
o Socially inappropriate behaviors
o Eating disturbances
o Sleep problems
o Diurnal/sleep-wake cycle disturbances
o Repetitive behavior
Mood disturbances (To meet measure, patient or knowledgeable informant must be screened for depression and at least one more symptom from this list):
o Anxiety
o Elation
o Irritability
o Mood lability/fluctuations
Thought and perceptual disturbances (To meet measure, patient or knowledgeable informant must be screened for at least one symptom from this list:
o Thought and perceptual disturbances
o Having fixed false beliefs (delusions)
o Hearing or seeing non-present entities (hallucinations)
o Paranoia
Examples of reliable and valid instruments that can be used to assess behavioral and psychiatric symptoms are:
Dementia Signs and Symptoms (DSS) Scale or Neuropsychiatric Inventory (NPI). For patients residing in nursing homes, it may be the Minimum Data Set (MDS). Other reliable and valid instruments may be used to assess individual measure components for activity disturbances, mood disturbances including depression, and thought and perceptual disturbances.
NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. In the event that a patient is not screened or partially screened during an eligible encounter for behavioral and psychiatric symptoms or the screening status is unknown submit G9921.
Numerator Options:
Performance Met: Screening Performed AND Positive AND Provision of Recommendations (G9919)
OR
Performance Met: Screening Performed AND Negative (G9920)
OR
Performance Not Met: No Screening Performed, Partial Screening Performed OR Positive Screen Without Recommendations and Reason is Not Given or Otherwise Specified (G9921)