MBHR17 Improved Efficiency: Time Interval for reporting results of cognitive assessment

Measure Title  

Improved Efficiency: Time Interval for reporting results of cognitive assessment

Measure Description:   

Percentage of patients, regardless of age, for which the referring provider or patient receives reporting of assessment results within 14 days of the completion of assessment.


Number of patients, regardless of age, who were referred for a cognitive or mental health assessment due to concerns about cognitive impairment, and who had an eligible encounter visit during the measurement period

DENOMINATOR NOTE: If there are multiple referrals for a patient during the performance period, use the first referral.

Denominator Criteria (Eligible cases):  

All patients, regardless of age, on the date of the encounter who were referred for a cognitive or mental health assessment due to concerns about cognitive impairment, and who had an eligible encounter visit during the measurement period.


Patient encounter during the performance period (CPT): 

90791; 96156; 96116; 96121; 96132; 96133; 96146; 96105; 96125; 96110


Patient was referred to another provider or specialist during the performance period.




Number of patients who were referred for and completed a standardized cognitive or mental status assessment for whom results were reported back to the patient, referring provider or treatment team within 14 days of completion of assessment.

NUMERATOR NOTE: The 14 day guideline period is defined as 14 days from the last date of assessment.  If interview and cognitive assessment are part of the same encounter though completed on separate dates, the 14 day guideline occurs after the testing CPT code.

*See definitions below for details


Provider: The clinician that provided the service of the intended measure.

Referral: A request from one eligible provider to another eligible provider for evaluation, treatment, or co-management of a patient’s condition. For this measure, referral indicates referral of a patient for a cognitive or mental status assessment. This term encompasses referral and consultation as defined by Centers for Medicare and Medicaid Services.

Report: A verbal summary or written document provided to the referral source by the provider of the assessment that includes description of the assessment findings, diagnostic information, and/or associated healthcare plan.

Feedback: A feedback session provided by the eligible clinician to the patient and/or caregiver which includes assessment findings, diagnostics, and/or health care plan and other treatment recommendations.


Resulting report should be completed after the referral was generated, and should be related to the referral for which it is attributed. If there are multiple reports regarding a given patient that are generated to the same referral source, use the first report to satisfy the measure. The provider to whom the patient was referred should be the same provider that generates and provides the report.

Numerator Options:

Performance Met:

Patient and/or caregiver underwent a cognitive or mental status assessment and was provided feedback of assessment results and treatment plan, as was the referring provider, within 14 days of completion of assessment.


Denominator Exception: 

Patient or provider limitations preclude meeting this timeframe. For example, patient limitations may include, but are not limited to: there is an appreciable change in the patient’s medical and/or cognitive status since the last date of testing which will impact interpretation of results, report delay due to a delay in receiving critical records, etc. Provider limitations may include, but are not limited to: report not sent to referring provider because referring provider no longer open and/or no longer present at that organization, etc.  


Feedback AND/OR report was not provided to patient and/or caregivers under the CURES act, which states: “Preventing Harm Exception It will not be information blocking for an actor to engage in practices that are reasonable and necessary to prevent harm to a patient or another person, provided certain conditions are met.”


Organizational policies or statutes that limit feedback to an evaluee (e.g., some forensic hospitals/jails/etc.).


Performance Not Met:

Patient and/or caregiver, and provider, did not receive feedback and/or a report within 14 days from the completion of testing from the provider.


Standardized cognitive assessment – refers to the administration of reliable and research-validated assessment methods or tests that cover one or a combination of the following cognitive domains: memory, language, visual-spatial, executive functioning, academic skills, developmental level, intellectual functioning, attention, and processing speed. Depending on medical needs, referral question, and patient characteristics, cognitive assessment may entail targeted assessment of a particular cognitive domain or a comprehensive assessment battery encompassing multiple domains. Psychological functioning may also be formally assessed to identify whether emotional or social factors are influencing cognitive functioning. Meeting performance for this measure is not limited to a specific cognitive test as long as it meets the above criteria and is commonly accepted within the medical community. Examples of well validated and commonly accepted cognitive tests can be found in Strauss, Sherman, & Spreen, A Compendium of Neuropsychological Tests [5].

The following list is illustrative of types of tests or test batteries that would meet this criterion and are not meant to be equal or interchangeable. Clinical judgment, commiserate with education and training, is needed in selecting and interpreting the chosen test(s).

Neuropsychological Assessment Battery (NAB)

Boston Diagnostic Aphasia Examination (BDAE)

California Verbal Learning Test-Third Edition (CVLT3)

Wechsler Memory Scale-Fourth Edition (WMS-IV)

Mental status examination – refers to an assessment of behavioral and cognitive functioning that includes descriptions of the following: level of consciousness, appearance, behavior, speech and motor activity, mood and affect, thought and perception, and attitude, insight and judgement. Mental status examinations also include assessment of higher cognitive abilities of alertness, language, memory, constructional ability and praxis, and abstract reasoning [6]. Examples are below:

Montreal Cognitive Assessment (MoCA)

Mini-Mental Status Examination (MMSE)

NQF Number    


NQS Domain

Communication and Care Coordination

High Priority


High Priority Type


Measure Type


Meaningful Measure Area

Prevention, Treatment, and Management of Behavioral and Mental Health

Inverse Measure


Proportional Measure


Continuous Variable Measure


Ratio Measure


Number of performance rates to be submitted


Measure Risk-Adjusted?


Care Setting

Ambulatory, Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Hospital, Hospital, Hospital Inpatient, Hospital Outpatient, Long Term Care, Nursing Home, Outpatient Services, Rehabilitation Facility, Rehabilitation Facility: Inpatient 

Includes Telehealth?    




Get in touch

0 of 350