CMS 139v8: Falls: Screening for Future Falls Risk

Measure: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
Measure TypeHigh Priority MeasureScoring
ProcessYesA higher percentage indicates better quality
DenominatorPatients aged 65 years and older with a visit during the measurement period
NumeratorPatients who were screened for future fall risk at least once within the measurement period
Denominator ExceptionsNone
Denominator Exclusions
  • Patients who were non-ambulatory at some point in the measurement period
  • Patients whose hospice care overlaps the measurement period

Patients who meet the following criteria will be included in the denominator:

  • Age is ≥ 65 years at the beginning of the Measurement Period

    AND

  • Have at least one eligible encounter during the Measurement Period finalized by the EC/EP

CPT: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99395, 99396, 99397, 99385, 99386, 99387, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 92002, 92004, 92012, 92014, 99401, 99402, 99403, 99404, 99315, 99316, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 92540, 92541, 92542, 92548

HCPCS: G0438, G0439

A patient will be excluded from this measure if they were assessed to be non-ambulatory during the Measurement Period OR were in hospice care during the Measurement Period.

To document a non-ambulatory assessment from the Fall Risk Screening flowsheet:

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the Fall Risk Screening flowsheet and click Add
  4. Click Add Column
  5. Select a Value from the Patient exempt due to following reason list
  6. Click OK to save

Selecting Bedrest/wheelchair for Gait assessment when completing the Morse Fall Scale in the Fall Risk Screening flowsheet will also exclude a patient from the measure.

To document hospice care services as a procedure, go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

SNOMED CT: 385763009, 385765002

Order Status must be marked as Pending or Complete.

SNOMED CT codes must be added as a Favorite in Preferences > Form Data > Orders to be accessible from the Orders/Referrals tab.

A patient will be counted in the numerator if they received a fall risk screening using the Morse Fall Scale assessment tool or through another screening method during the Measurement Period.

To document a screening using the Morse Fall Scale:

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the Fall Risk Screening flowsheet and click Add
  4. Click Add Column
  5. Select a Value for all questions in the screening
  6. Click OK to save

To document the performance of a fall risk screening with a different screening tool:

  1. Go to Encounter > Flowsheets/Labs > Standard Flowsheets
  2. Click Add New Flowsheet
  3. Select the Fall Risk Screening flowsheet and click Add
  4. Click Add Column
  5. Select the Done checkbox for Other fall risk assessment performed
  6. Click OK to save

https://ecqi.healthit.gov/ecqm/ep/2020/cms139v8

 

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