CMS 156v12: Use of High-Risk Medications in Older Adults

Measure: Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class. Three rates are reported:

  • Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class

  • Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses

  • Total rate (the sum of the two numerators divided by the denominator, deduplicating for patients in both numerators)
Measure Type High Priority Measure Scoring
Process Yes A lower percentage indicates better quality
Denominator Patients 65 years and older at the end of the measurement period who had a visit during the measurement period
Numerator

Rate 1 : Patients with at least two orders of high-risk medications from the same drug class on different days

  1. At least two orders of high-risk medications from the same drug class

  2. At least two orders of high-risk medications from the same drug class with summed days supply greater than 90 days

  3. At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria

Rate 2: Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines) on different days except for appropriate diagnoses

  1. Patients with two or more antipsychotic prescriptions ordered on different days, and who did not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the Index Prescription Start Date (IPSD) for antipsychotics.

  2. Patients with two or more benzodiazepine prescriptions ordered on different days, and who did not have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines

Total rate (the sum of the two previous numerators, deduplicated)
Denominator Exceptions None
Denominator Exclusions

  • Patients in hospice care for any part of the measurement period

  • Patients receiving palliative care for any part of the measurement period

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

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

    AND

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

CPT: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99395, 99396, 99397, 99385, 99386, 99387, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 92002, 92004, 92012, 92014, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99315, 99316, 99318, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 98969, 98970, 98971, 98972, 99421, 99422, 99423, 99458, 98966, 98967, 98968, 99441, 99442, 99443, 98980, 98981, 99444, 99457

HCPCS: G0438, G0439, G0071, G2010, G2012, G2061, G2062, G2063, G2250, G2251, G2252

A patient will be excluded from this measure if they meet any of the following conditions:

  • Is in hospice care for any part of the Measurement Period
  • Is receiving palliative care for any part of the Measurement Period

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

CPT: 99377, 99378

HCPCS: G0182

Order Status must be marked as Pending or Complete.

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

HCPCS: G9996, G9473, G9474, G9475, G9476, G9477, G9478, G9479, Q5003, Q5004, Q5005, Q5006, Q5007, Q5008, Q5010, S9126, T2042, T2043, T2044, T2045, T2046

Order Status must be marked as Complete.

Palliative care services can be documented using the FACIT-Pal Questionnaire flowsheet, as an order, or as a diagnosis.

  1. Go to Encounter > Flowsheets/Labs > Standard or Chart > Flowsheets/Labs > Standard

  2. Click Add New Flowsheet

  3. Select the FACIT-Pal Questionnaire flowsheet and click Add

  4. Click Add Column

  5. Populate the patient's responses to the questions as appropriate

  6. Click OK to save

Go to Encounter > Orders/Procedure > Orders/Referrals and click Add to add one of the eligible codes listed below:

HCPCS: G9054, M1017

Order Status must be marked as Complete.

Diagnoses are documented in the Assessment tab of an encounter. The eligible diagnosis code for palliative care is:

ICD-10: Z51.5

Rate 1: A patient will be counted in the numerator if the patient has at least two orders of high-risk medications from the same drug class on different days.

  • At least two orders of high-risk medication from the same drug class

    OR

  • At least two orders of high-risk medication from the same drug class with summed days supply greater than 90 days

    OR

  • At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria

A high-risk medication is identified as: a prescription for medications classified as high-risk at any dose and for any duration; or as prescriptions for medications classified as high-risk at any dose with greater than a 90-day supply.

A comprehensive list of eligible high-risk medications can be located here.

Rate 2: A patient will be counted in the numerator if the patient has:

  • Two or more orders for antipsychotics on different days, and who did not have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the IPSD for antipsychotics.

  • Two or more orders for benzodiazepines on different days, and who did not have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines

A comprehensive list of eligible antipsychotics and benzodiazepines can be located here.

The Total Rate is the sum of Rate 1 and Rate 2, deduplicated.

For Rate 2:

  • A patient with two or more antipsychotic prescriptions ordered will be excluded if they have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the Measurement Period and the first prescription start date for antipsychotics.

  • A patient with two or more benzodiazepine prescriptions ordered will be excluded if they have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the Measurement Period and the first prescription start date for benzodiazepines.

Diagnoses are documented in the Assessment tab of an encounter. A comprehensive list of eligible diagnosis codes for the conditions that meet the Numerator Exclusions can be located here.

https://ecqi.healthit.gov/ecqm/ec/2024/cms0156v12

 

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