CMS Measure ID: #291
Collection Type: CQM, MVP
Reporting Frequency: Once per patient per year
High Priority: No
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of Parkinson’s disease 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 submissions; however, these codes may be submitted for those registries that utilize claims data.
Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed for cognitive impairment or dysfunction once during the measurement period.
2022 Benchmarks (from 2020 CMS data)
Topped out: Yes
Capped at 7: Yes
Minimum: 0 – 40.24
Decile 3: 40.25 – 75.57
Decile 4: 75.58 – 92.49
Decile 5: 92.5 – 99.99
Decile 10: 100 – 100
All patients with a diagnosis of Parkinson’s Disease
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
Diagnosis for Parkinson’s disease (ICD-10-CM): G20
Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99242*, 99243*, 99244*, 99245*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99421, 99422, 99423, 99441, 99442, 99443, 99483
Patients (or care partner as appropriate) who were assessed for cognitive impairment or dysfunction once during the measurement period.
Assessed – Is defined as a discussion with the patient or care partner or use of a screening tool OR referral to neuropsychologist for testing.
Screening tools approved for use in this measure include:
Dementia Rating Scale (DRS-2)
Mini-Mental Status Examination (MMSE)
Montreal Cognitive Assessment (MoCA)
Parkinson’s Disease Dementia – Short Screen (PDD-SS)
Parkinson Neuropsychiatric Dementia Assessment (PANDA)
Parkinson’s Disease- Cognitive Rating Scale (PD-CRS)
Patient-Reported Outcomes Measurement Information System (PROMIS)
Scales for Outcomes of Parkinson’s Disease – Cognition (SCOPA- Cog)
Performance Met: Cognitive impairment or dysfunction assessed (3720F)
Denominator Exception: Patient or care partner decline assessment (G0036)
Denominator Exception: On date of encounter, patient is not able to participate in assessment or screening, including non-verbal patients, delirious, severely aphasic, severely developmentally delayed, severe visual or hearing impairment and for those patients, no knowledgeable informant available. (G0037)
Performance Not Met: Cognitive impairment or dysfunction was not assessed, reason not otherwise specified (3720F with 8P)