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PRIME Project 1.4 Patient Safety in the Ambulatory Care SettingMetric Specification Manual V2.2

Document Control LogVersion Date DetailsV1.0 2/29/16 Metric specifications not arranged by Project

Metric specifications in native format without editingV2.0 3/7/16 Metrics arranged by Project

Metric specifications edited for PRIMEV2.1 4/29/16 Added PRIME Eligible Population for DMPHs

Added sentence requiring inclusion of individuals who meet either Population #1or #2 criteria.Modified continuous enrollment language for PRIME Eligible Population #2 to be 12 months during the Measurement PeriodReplaced “Appendix 2” with “Table 5” in GPP footnoteDeleted reporting of three rates in 1.4.2 NQF 2371 Revised specification and Summary Table for 1.4.1 Abnormal Results Follow-up

V2.2 5/31/16 Approved by DHCSAdded exclusion of inpatient encounters in PRIME Eligible Population #1Added PRIME Eligible Population Tenure and Exclusion criteriaRevised summary table for 1.4.1 to align with measure numerator/denominatorRemoved the word “abnormal” in 1.4.1 denominator to align with the INR & mammogram denominators in the same metric.Added Exclusions and definition of “Ambulatory Care Tests/Ambulatory Setting” in 1.4.1 Abnormal Results Follow-upAdded “INR Test” and “Interval” language from original specs to Numerator Details under 1.4.3 NQF 0555

Metric Questions or Feedback: A link to a form is provided. Please complete one form for each request for clarification per metric. You may submit additional requests as needed.

Measurement PeriodsDemonstration Year Mid-Year Report Measurement Period Final Year-End Report Measurement PeriodDY 11 Not applicable Jul 1, 2015 – Jun 30, 2016DY12 Jan 1, 2016 – Dec 31, 2016 Jul 1, 2016 – Jun 30, 2017DY13 Jan 1, 2017 – Dec 31, 2017 Jul 1, 2017 – Jun 30, 2018DY14 Jan 1, 2018 – Dec 31, 2018 Jul 1, 2018 – Jun 30, 2019DY15 Jan 1, 2019 – Dec 31, 2019 Jul 1, 2019 – Jun 30, 2020

Note: Specifications for PRIME measures that are CMS Core measures refer to CMS value sets1

1 A CMS value set is the complete set of codes used to identify a service or condition included in a measure. The value set references are underlined in the specifications (e.g. BMI Percentile Value Set). The Value Set Directory is available at: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2015-Adult-Value-Set-Directory.zip, Accessed on 2/26/2016. For a Value Set Directory User Manual, refer to Appendix A in the 2015 Core Set of Adult Health Care Quality Measures for Medicaid. of 17 v2.2 5/31/16, DHCS ApprovedReturn to Summary Table Questions or feedback on metrics: complete form

https://www.surveymonkey.com/r/VMM9X9N

https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-Adult-Core-Set-Manual.pdf


http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2015-Adult-Value-Set-Directory.zip

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/2015-Adult-Value-Set-Directory.zip



PRIME Eligible Population for Designated Public Hospitals (DPHs) only:

The PRIME Eligible Population includes the combination of both Population #1 and Population #2. An individual does not have to meet criteria of both Population #1 and Population #2. Any individual who meets either PRIME Eligible Population #1 criteria or PRIME Eligible Population #2 criteria must be included in the PRIME Eligible Population.

Population #1: Individuals of all ages with at least 2 encounters with the PRIME Entity Primary Care team during the measurement period.

A Primary Care team encounter is counted if occurred with a member of the Primary Care Team from Family Medicine, Internal Medicine, or Pediatrics. The PRIME Entity may choose to include populations who are seen for primary care in a specialty clinic (e.g. HIV)

Encounters include either a face-to-face visit with a primary care provider OR any encounter included in the list of eligible non-traditional service types described in the Global Payment Program2 (for PRIME, encounters not limited to uninsured individuals.)

Only encounters with the Primary Care team in the ambulatory setting will be counted toward the above 2 encounter requirement. Encounters with primary care team members in the inpatient setting do not count toward the two primary care encounter requirement. [This does not impact the expansion of the PRIME Eligible Population to include inpatient or acute care utilization as specified by the Project Target Population criteria e.g. in Domain 3]

Population #2Individuals of all ages who are in Medi-Cal Managed Care with 12 months of continuous assignment to the PRIME Entity during the Measurement Period.

No more than one gap in enrollment or assignment with the PRIME Entity of up to 45 days during the Measurement Period.

Individual must be enrolled in the primary plan and assigned to the PRIME Entity on the final day of the Measurement Period.

PRIME Eligible Population for District Municipal Hospitals (DMPHs) only:

The PRIME Eligible Population is all individuals with at least two encounters by the participating PRIME entity among Medi-Cal Beneficiaries.

2 Non-traditional service encounters as listed in California’s MediCal 2020 Special Terms and Conditions Attachment FF: Global Payment Program Valuation Protocol, Table 5: Categories of Service and Point Values, Non-Traditional of 17 v2.2 5/31/16, DHCS ApprovedReturn to Summary Table Questions or feedback on metrics: complete form


http://www.dhcs.ca.gov/provgovpart/Documents/Waiver%20Renewal/MC2020AttFF.pdf


Tenure Criteria for DPH/DMPH PRIME Eligible Population Encountered Lives1. The first of the two required primary care encounters (DPH) or Medi-Cal encounters (DMPH) must

occur during the first 6 months of the measurement period2. The second required (primary care) encounter may occur at any point during the measurement

period.3. The two (primary care) encounters during the measurement period fulfilling the PRIME Eligible

Population eligibility criteria cannot occur on the same day.

Exclusion Criteria for DPH/DMPH PRIME Eligible PopulationExclusion for patients no longer the responsibility of the PRIME Entity at the end of the measurement period:

1. Any patient meeting the PRIME Eligible Population Encountered Lives criteria in a given measurement period who then experiences any of the following scenarios, will be removed from the PRIME Eligible Population for that measurement period, when the PRIME entity has documentation that before the end of the measurement period:

a. The patient has died.b. The patient has changed their care to a PCP in a health system that is not the PRIME Entity.c. The patient has been incarcerated.

PRIME Project 1.4 Target Population is the PRIME Eligible Population as defined above.

of 17 v2.2 5/31/16, DHCS ApprovedReturn to Summary Table Questions or feedback on metrics: complete form



Summary Table1.4.2 - NQF 2371: Annual Monitoring for Patients on Persistent Medications

Specification Source: : 2015 Core Set of Adult Health Care Quality Measures for Medicaid v. April 2015

Numerator: This measure is reported as a total rate. For annual monitoring for patients on ACE inhibitors or ARBs: the number of patients with at least one serum potassium and serum creatinine therapeutic monitoring test in the measurement year. For annual monitoring for patients on digoxin: the number of patients with at least one serum potassium, one serum creatinine, and a serum digoxin therapeutic monitoring test in the measurement year. For annual monitoring for patients on diuretics: the number of patients with at least one serum potassium and serum creatinine therapeutic monitoring test in the measurement year. For the total rate: sum of the 3 numerators.

Denominator: Patients age 18 and older as of the end of the measurement year who are on selected persistent medications (ACE Inhibitors/ARB, Digoxin or Diuretics.)

1.4.1 - Abnormal results follow-up: % of abnormal results with appropriate and timely documentation and follow-up

Specification Source: PRIME Innovative Measure Steward

Numerator: Number of denominator serum Potassium, INR tests or mammograms that have had appropriate follow-up

Denominator: The number of serum potassium, INR tests or mammograms completed in the ambulatory setting during the measurement year in PRIME Eligible Population patients age 18 and older, as of the end of the measurement period, who are on selected persistent medications (ACE Inhibitors/ARB, Diuretics, or Warfarin), or who was assessed for breast cancer with a mammogram.

1.4.3 - NQF 0555: INR Monitoring for Individuals on Warfarin

Specification Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NQF-0555.zip

Numerator: The number of individuals in the denominator who have at least one INR monitoring test during each 56-day interval with active warfarin therapy.

Denominator: Individuals at least 18 years of age as of the beginning of the measurement period with warfarin therapy for at least 56 days during the measurement period.



https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NQF-0555.zip

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/NQF-0555.zip



1.4.2 - NQF 2371 Annual Monitoring for Patients on Persistent Medications

MEASURE MPM-AD: ANNUAL MONITORING FOR PATIENTS ON PERSISTENTMEDICATIONS

National Committee for Quality Assurance

A. DESCRIPTIONPercentage of individuals in the Project 1.4 Target Population age 18 and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Report as a total rate.

• Annual monitoring for individuals on angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB)

• Annual monitoring for individuals on digoxin• Annual monitoring for individuals on diuretics• Total rate (the sum of the three numerators divided by the sum of the three

denominators)

Data Collection Method: Administrative

Guidance for Reporting:• This measure applies to individuals in the Project 1.4 Target Population age 18 and older. • Include all paid, suspended, pending, and denied claims.• NCQA’s list of NDC codes for ACE Inhibitors/ARBs can be found at:

h tt p : / / ww w . nc q a . o r g / H E D I S Q ua li t y M easu r e m en t / HED I S M easu r es / HED I S 2015 / HED I S 2 015NDCLicense/ HEDI S2015FinalNDCL ist s. aspx

B. ELIGIBLE POPULATION

Age Age 18 and older as of the last day of the measurement period



Measure MPM-AD: Annual Monitoring for Patients on Persistent Medications 6

Event/Diagnosis

Individuals on persistent medications (i.e., Individuals who received at least 180 treatment days of ambulatory medication in the measurement year). Refer to Additional Eligible Population Criteria for each rate.Treatment days are the actual number of calendar days covered with prescriptions within the measurement period (i.e., a prescription of 90 days’ supply dispensed on first day of the last month of the measurement year counts as 30 treatment days). Sum the days’ supply for all medications and subtract any days’ supply that extends beyond the last day of the measurement period.Note: Medications dispensed in the year prior to the measurement year must be counted toward the 180 treatment days.

C. ADMINISTRATIVE SPECIFICATIONReport as a total rate. The total rate is the sum of the three numerators divided by the sum of the three denominators.

Rate 1: Annual Monitoring for Individuals on ACE Inhibitors or ARBsAdditional Eligible Population Criteria

Individuals who received at least 180 treatment days of ACE inhibitors or ARBs, during the measurement year. Refer to Table MPM-A (which corresponds to NDC code Table CDC-L) to identify ACE inhibitors and ARBs.

Individuals may switch therapy with any medication listed in Table MPM-A during the measurement year and have the day’s supply for those medications count toward the total 180 treatment days (i.e., an individual who received 90 days of ACE inhibitors and 90 days of ARBs meets the denominator definition for rate 1).

Table MPM-A. ACE Inhibitors/ARBs

Description Prescription

Angiotensin converting enzyme inhibitors

Benazepril Captopril Enalapril Fosinopril

Lisinopril Moexipril Perindopril Quinapril

RamiprilTrandolapril

Angiotensin IIinhibitors

Azilsartan Candesartan Eprosartan Irbesartan

Losartan Olmesartan Telmisartan Valsartan

.



PRIME Project 1.4 Patient Safety in the Ambulatory Care Setting Metric Specification Manual v2.1


Antihypertensive combinations

Aliskiren-valsartan Amlodipine-benazepril Amlodipine-hydrochlorothiazide-valsartanAmlodipine- hydrochlorothiazide- olmesartanAmlodipine- olmesartanAmlodipine- telmisartanAmlodipine-valsartanAzilsartan- chlorthalidone

Benazepril- hydrochlorothiazideCandesartan- hydrochlorothiazideCaptopril- hydrochlorothiazideEnalapril- hydrochlorothiazideEprosartan- hydrochlorothiazideFosinopril- hydrochlorothiazideHydrochlorothiazide- irbesartanHydrochlorothiazide- lisinopril

Hydrochlorothiazide-losartanHydrochlorothiazide-moexiprilHydrochlorothiazide-olmesartanHydrochlorothiazide-quinaprilHydrochlorothiazide-telmisartanHydrochlorothiazide-valsartanTrandolapril- verapamil

NumeratorAt least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement year. Any of the following during the measurement year meet criteria:

• A lab panel test (Lab P anel V a l ue S e t )• A serum potassium test (S e r um P o t ass i u m V a l ue S e t ) and a serum creatinine test

(S e r um C r e a t i n i ne V a l ue S e t )

The tests do not need to occur on the same service date, only within the measurement year.

Rate 2: Annual Monitoring for Individuals on DigoxinAdditional Eligible Population Criteria

Individuals who received at least 180 treatment days of digoxin (Table MPM-B) during the measurement year.

Table MPM-B. Drugs to Identify Individuals on Digoxin


Inotropic agents Digoxin




NumeratorAt least one serum potassium, at least one serum creatinine, and at least one serumdigoxin therapeutic monitoring test in the measurement year. Any of the following during the measurement period meet criteria:

• A lab panel test (Lab P anel V a l ue S e t ) and a serum digoxin test (D i g o x i n Le v el V a l ue

S e t ).• A serum potassium test (S e r um P o t ass i u m V a l ue S e t ), and a serum creatinine test

(S e r um C r e a t i n i ne V a l ue S e t ) and a serum digoxin test (Di g o x i n Le v el V a l ue S e t ).

The tests do not need to occur on the same service date, only within the measurement period.

Rate 3: Annual Monitoring for Individuals on DiureticsAdditional Eligible Population Criteria

Individuals who received at least 180 treatment days of a diuretic (Table MPM-C), during the measurement year.

Individuals may switch therapy with any medication listed in Table MPM-C during the measurement year and have the day’s supply for those medications count toward the total 180 treatment days.

Table MPM-C. Drugs to Identify Individuals on Diuretics


Antihypertensive combinations

Aliskiren-hydrochlorothiazideAliskiren-hydrochlorothiazide- amlodipineAmiloride-hydrochlorothiazideAmlodipine-hydrochlorothiazide- olmesartanAmlodipine-hydrochlorothiazide- valsartanAtenolol-chlorthalidone Azilsartan-chlorthalidone Benazepril-hydrochlorothiazide Bendroflumethiazide-nadolol Bisoprolol-hydrochlorothiazide Candesartan-hydrochlorothiazide Captopril-hydrochlorothiazide Chlorthalidone-clonidineEnalapril-hydrochlorothiazide

Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-methyldopa Hydrochlorothiazide-metoprolol Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-propranolol Hydrochlorothiazide-quinapril Hydrochlorothiazide-spironolactoneHydrochlorothiazide-telmisartan Hydrochlorothiazide-triamterene Hydrochlorothiazide-valsartan




Loop diuretics BumetanideEthacrynic acid

FurosemideTorsemide

Potassium- sparing diuretics

AmilorideEplerenone

SpironolactoneTriamterene

Thiazide diuretics Chlorothiazide Chlorthalidone Hydrochlorothiazide

Indapamide Methyclothiazide Metolazone

Numerator

At least one serum potassium and a serum creatinine therapeutic monitoring test in the measurement period. Any of the following during the measurement period meet criteria:

• A lab panel test (Lab P anel V a l ue S e t ).• A serum potassium test (S e r um P o t ass i u m V a l ue S e t ) and a serum creatinine test

(S e r um C r e a t i n i ne V a l ue S e t ).

The tests do not need to occur on the same service date, only within the measurement period.

Exclusions (optional)Exclude individuals from each eligible population rate who had an inpatient (acute or non-acute) claim/ encounter during the measurement period.




1.4.1 - Abnormal results follow-up: % of abnormal results with appropriate and timely documentation and follow-up

I. BACKGROUND

Measure Title: Abnormal Results Follow-Up

Measure Description% of abnormal ambulatory care results with appropriate and timely documentation and follow-up for Potassium, INR, and Mammograms.

Project(s)1.4 Patient Safety in the Ambulatory Care Setting

Measure Steward Entity(/ies), OrganizationAlameda Health System

II. REPORTINGMeasure Description:

This measure assesses the percentage of patients 18 years of age and older who received any of each of the following ambulatory care tests and follow-up during the measurement period: At least 180 treatment days of ACE/ARB or Diuretic, at least one potassium monitoring event, and follow-up appropriate to the result; warfarin therapy for at least 56 days, at least one INR monitoring test during each 56-day interval with active warfarin therapy, and follow-up appropriate to the result; and/or was assessed for breast cancer with a mammogram and received follow-up appropriate to the resultant BIRADs assessment.

The metric will be reported as 3 individual rates.

Potassium: Appropriate Monitoring and Follow-upThis measure assesses the percentage of ambulatory care serum potassium tests performed on patients 18 years of age and older who received at least 180 treatment days of ACE, ARB or Diuretic therapy during the measurement year, at least one potassium monitoring event for the therapeutic agent in the measurement year, and follow-up appropriate to the results of that potassium monitoring event.

Numerator Statement:This measure is calculated and reported as only one total rate.




Measure Numerator Number of denominator serum Potassium tests that have had appropriate follow-up, as per the following:

Potassium (K) 3.5 – 5.1 Normal range, no lab follow-up Potassium ≥3 and <3.5 Follow up lab in 4 weeks Potassium ≥5.2 and < 6 Follow up lab in 10 days Potassium <3 or ≥6 Documented as a critical lab value and that the ordering clinician (or

responsible delegate) has been informed within 24 hours

Numerator Code/s (CPT, ICD10, other) Follow-up Date of Follow-up Date and time of documentation that ordering clinician has been informed

Denominator Statement:The number of serum potassium tests completed in the ambulatory setting during the measurement year in PRIME Eligible Population patients age 18 and older, as of the end of the measurement period, who are on selected persistent medications (ACE Inhibitors/ARB or Diuretics) for at least 180 days.

Denominator Codes: (CPT, ICD10, other) Patient ID Data of prescriptions Lab code Date of Lab result Lab Result Medications (NDC code sets): See Abnormal Result Spreadsheet

Exclusion/sTests ordered from the emergency department or inpatient setting. Tests ordered from urgent care settings that are located within an emergency department may also be excluded.

Reporting Business Logic [Pending]

Definitions as applicable Ambulatory care tests/Ambulatory setting Any of the referenced tests ordered from any primary care, specialty care or urgent care setting. Tests may be ordered by primary or specialty care providers.




Other Notes as applicablePotassium ordering from Annual Monitoring for Patients on Persistent Medications.If follow-up serum Potassium tests are performed in the ambulatory setting and are also outside the normal range, they too will be will be included in the denominator, with subsequent follow-up serum Potassium tests being included in the numerator.

Measurement Period as applicableDY 11: Final End of Year:

July 1, 2015 through June 30, 2016

DY 12-DY 15: Interim Mid-Year: January 1, 20xx through December 31, 20xx Final End of Year: July 1, 20xx through June 30, 20xx

INR: Appropriate Monitoring and Follow-up

Measure Numerator Number of denominator INR's that have had appropriate follow-up as per the following:

INR < 2 follow up with a new lab in 4 weeks INR 2-3.5No lab follow-up INR > 3.5 and <4.9 follow up with a new lab in 10 days INR >4.9 Documented as a critical lab value and that the ordering clinician (or responsible

delegate) has been informed within 24 hours

Numerator Code/s (CPT, ICD10, other) Follow-up Date of Follow-up Date and time of documentation that ordering clinician has been informed

Measure DenominatorThe number of INR's completed in the ambulatory setting during the measurement year for individuals in the Target Population, at least 18 years of age as of the beginning of the measurement period with warfarin therapy for at least 56 days during the measurement period and who have at least one INR monitoring test during each 56-day interval with active warfarin therapy. Please Refer to Specs for Metric NQF 0555 for all specifications necessary to calculate the denominator for the INR portion of the Abnormal Results Follow-up metric.

Denominator Code/s (CPT, ICD10, other) Date and time of index INR See NQF 0555 Please Refer to Specs for Metric NQF 0555




Exclusion/sIndividuals monitoring INR at home. Individuals who are in long-term care during the measurement period.

INR tests ordered from the emergency department or inpatient setting. INR tests ordered from urgent care settings that are located within an emergency department may also be excluded.

Reporting Business Logic

Definitions as applicable Ambulatory care tests/Ambulatory setting Any of the referenced tests ordered from any primary care, specialty care or urgent care setting. Tests may be ordered by primary or specialty care providers.

Other Notes as applicableIf follow-up INR’s are performed in the ambulatory setting and are also outside the normal range, they too will be will be included in the denominator, with subsequent follow-up INR’s being included in the numerator.




BIRADs Follow-up

Measure Numerator Number of denominator mammograms that received appropriate follow-up based on the results of the BIRAD assessment, as per the following:

BIRADS = 0 Recall for additional images or comparison with prior mammograms within 30 days

BIRADS = 1 or 2 Routine follow-up BIRADS = 3 6 month follow up study




Numerator Code/s (CPT, ICD10, other) Follow-up Date of Follow-up

Measure DenominatorNumber of mammograms performed PRIME Eligible Population individuals during the measurement period

Denominator Code/s (CPT, ICD10, other) Patient ID Patient DOB Date of Mammogram result Mammogram BIRADS Assessment score

Exclusion/sAny Mammogram with a result of BIRADS 4 or 5.

Mammograms ordered from the emergency department or inpatient setting. Mammograms ordered from urgent care settings that are located within an emergency department may also be excluded.

Reporting Business Logic None

Definitions as applicable

Ambulatory care tests/Ambulatory setting Any of mammograms ordered from any primary care, specialty care or urgent care setting. Tests may be ordered by primary or specialty care providers.

Other Notes as applicableNone







III. RATIONALE

Rationale for Measure

Scientific Acceptability




1.4.3 - NQF 0555: INR Monitoring for Individuals on Warfarin

Brief Description

Percentage of individuals in the Project 1.4 Target Population at least 18 years of age as of the beginning of the measurement period with at least 56 days of warfarin therapy who receive an International Normalized Ratio (INR) test during each 56-day interval with warfarin

Numerator Statement: The number of individuals in the denominator who have at least one INR monitoring test during each 56-day interval with active warfarin therapy

Time Period for Data: The time period of the data is defined as any time during the measurement period (12 consecutive months).

Numerator Details: Individuals in the denominator who have at least one INR test performed during each 56-day interval with warfarin therapy, or 100% INR monitoring compliance, will be counted in the numerator. Each 56-day interval with an INR testis used to calculate the INR compliance rate for the individual. An interval with a hospitalization of more than 48 hours is considered an interval with an INR test.

INR Test: Prothrombin time, CPT 85610“Warfarin usage” or “warfarin therapy” is determined by the start date of the first prescription for warfarin up through the start date of the last prescription for warfarin plus the days’ supply from the last claim.

Interval: 56 daysThe first day of the first 56-day interval is the start date of the first warfarin prescription, and the last day of the first 56-day interval is the start date of the first warfarin prescription + 55. The subsequent 56-day interval starts on the day after the first 56-day interval and ends 56 days following the first 56-day interval, as long as this end date occurs within the warfarin therapy time frame. This process continues until a calculated 56-day interval end date does not occur within the warfarin therapy time frame. If there are fewer than 56 days of warfarin therapy remaining, those remaining days are not counted in any interval in determining the numerator. Only full 56-day intervals are used for calculating the numerator.

For individuals who died during the measurement year, set warfarin therapy end date to be the death date of the individual

Denominator DetailsProject 1.4 Target Population

Active Ingredients by Class




Anticoagulants: warfarinNote: The active ingredient is limited to oral formulations only.

Denominator ExclusionsIndividuals who are monitoring INR at home

Optional Exclusion CriteriaIndividuals who are in long-term care (LTC) during the measurement period

Denominator Exclusion Details:Table 1. HCPCS Codes for INR Monitoring at HomeG0248 - DEMONSTRATE USE HOME INR MONG0249 - PROVIDE TEST MATS & EQUIP HOME INRG0250 - MD INR TEST REVIEW INTER MGMT

Stratification Details/Variables S.12.Depending on the operational use of the measure, measure results may be stratified by:

State Plan ACOs* Physician Group** Age – Divided into six categories: 18-24, 25-44, 45-64, 65-74, 75-84, and 85+ years Race/Ethnicity Dual Eligibility Status New Warfarin User vs. Continuous Warfarin User: “New” users are defined as those individuals

with no warfarin prescriptions during the 180 days prior to the first warfarin prescription in the current measurement period.

Diagnosis Indications for Warfarin: Atrial Fibrillation, Acute Myocardial Infarction, Venous Thromboembolism, Stroke, Mechanical Heart Valve

*ACO attribution methodology is based on where the beneficiary is receiving the plurality of his/her primary care services and subsequently assigned to the participating providers.**See Calculation Algorithm/Measure Logic S.18 below for physician group attribution methodology used for this measure.

For full measure specification, see NQF 0555 Measure Information Form and Code Table

