Meaningful Use (MU) Quality Measure Specifications v.1.0

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Meaningful Use (MU) Quality

Measure Specifications

v.1.0

70 Royal Little Drive Providence, RI 02904

Disclaimer: This document is prepared as a guide only. A provider can achieve Meaningful Use by using the functionality in the Ingenix CareTracker software. Providers are responsible for their actions and office practices,

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1 Overview... 4

2 NQF 0013 - Hypertension Blood Pressure Measurement... 5

2.1 Overview ... 5

2.2 Population Criteria... 5

3 NQF 0018 - Controlling High Blood Pressure... 7

3.1 Overview ... 7

3.2 Population Criteria... 7

4 NQF 0024 - Weight Assessment and Counseling for Children and Adolescents... 10

4.1 Overview ... 10

4.2 Population Criteria 1... 10

4.3 Population Criteria 2... 12

4.4 Population Criteria 3... 14

5 NQF 0028A - Tobacco Use Assessment ... 17

5.1 Overview ... 17

5.2 Population Criteria... 17

6 0028B - Tobacco Cessation Intervention ... 18

6.1 Overview ... 18

6.2 Population Criteria... 18

7 NQF 0031 - Breast Cancer Screening... 20

7.1 Overview ... 20

7.2 Population Criteria... 20

8 NQF 0032 - Cervical Cancer Screening ... 22

8.1 Description ... 22

8.2 Population Criteria... 22

9 NQF 0033 - Chlamydia Screening for Women ... 24

9.1 Overview ... 24

9.2 Population Criteria 1... 24

9.3 Population Criteria 2... 27

9.4 Population Criteria 3... 31

10 NQF 0034 - Colorectal Cancer Screening ... 36

10.1 Description ... 36

10.2 Population Criteria... 36

11 NQF 0038 - Childhood Immunization Status... 39

11.1 Overview ... 39

11.2 Population Criteria 1... 39

11.3 Population Criteria 2... 40

11.4 Population Criteria 3... 40

11.5 Population Criteria 4... 41

11.6 Population Criteria 5... 42

11.7 Population Criteria 6... 43

11.8 Population Criteria 7... 43

11.9 Population Criteria 8... 44

11.10 Population Criteria 9... 45

11.11 Population Criteria 10... 46

11.12 Population Criteria 11... 46

11.13 Population Criteria 12... 49

12 NQF 0041 - Preventive Care and Screening Influenza... 53

12.1 Overview ... 53

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Contents

13 NQF 0043 - Pneumonia Vaccination Status for Older Adults ... 55

13.1 Overview ... 55

13.2 Population Criteria... 55

14 NQF 0421 - Adult Weight Screening and Follow Up ... 56

14.1 Overview ... 56

14.2 Population Criteria 1... 56

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Overview

1 Overview

This document provides information you need for understanding and calculating data for the meaningful use Quality Measures. Each

measure listed in the document consists of two main sections that include an overview and information on the population criteria.



Overview – This section provides the National Quality Forum (NQF) ID used for identifying the measure and a description about the

measure.



Population Criteria – This section includes four main components that include initial population, denominator, numerator, and exclusions

for the measurement period. The measurement period is defined as the year to date time. Each of these components also includes

information on how to use CareTracker to satisfy each criterion. Additionally, each component contains measure elements that are

joined together with OR, and AND statements. The graphic displayed below describes each component and provides guidance on how

to read the information provided.

Figure 1 Population Criteria Overview

Important:

The Clinical Quality Measures (CQMs) in CareTracker are developed from the draft National Quality Forum (NQF) e-Measure

specifications, which were published in November 2010. The NQF is commissioned by CMS to develop all 44 e-Measures for Stage 1

Meaningful Use and an additional 69 for Stage 2. NQF finalized all 113 measures in February 2011, and CareTracker is reviewing the new

specifications and making the appropriate edits to the 12 CQMs, which are released. The next 24 CQMs to be released in 2011 will follow

the final NQF e-Measure specifications from the beginning. The CQM specifications are subject to change when CareTracker is given

updated specifications by NQF and will be communicated via release notes.

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NQF 0013 - Hypertension Blood Pressure Measurement

2 NQF 0013 - Hypertension Blood Pressure Measurement

2.1 Overview

Measure ID NQF 0013

Description The percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at

least two office visits, with Blood Pressure (BP) recorded.

2.2 Population

Criteria

Initial Population

All patients 18 years or older during the measurement period;

Denominator

AND: Two or more visit encounters during the measurement period; CareTracker Satisfier

Medical Records Module > Encounters.

Note: The encounter must be a visit type encounter or a custom encounter flagged as an “office visit” via the Custom Encounters application in the Administration module.

AND: Active diagnosis: Hypertension; CareTracker Satisfier

o

Medical Records module > Problem List , OR

o

A submitted claim/encounter contains any one of the following ICD-9 codes identifying hypertension.

Table 1 Codes to Identify Hypertension

Description ICD-9-CM Diagnosis

Hypertension 401.0, 401.1, or 401.9.

Numerator

AND: Physical exam finding: Blood pressure; CareTracker Satisfier

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NQF 0013 - Hypertension Blood Pressure Measurement

o

Medical Records Module > Vital Signs > Blood Pressure field.

Figure 2 Blood Pressure Field

Exclusions

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NQF 0018 - Controlling High Blood Pressure

3 NQF 0018 - Controlling High Blood Pressure

3.1 Overview

Description The percentage of patients 18-85 years of age who had a diagnosis of hypertension and Blood Pressure (BP) was adequately

controlled during the measurement year.

3.2 Population

Criteria

All patients 18 to 85 years of age during the measurement period;

Denominator

AND: One or more visit encounters during the measurement period; CareTracker Satisfier

AND: Active diagnosis: Hypertension; CareTracker Satisfier

o

Medical Records module > Problem List , OR

o

A submitted claim/encounter contains any one of the following ICD-9 codes listed.

Table 2 Codes to Identify Hypertension

Hypertension 401.0, 401.1, or 401.9.

AND: Physical exam finding: Blood pressure; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Blood Pressure field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > PE tab > Blood Pressure field, OR

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AND NOT: One of the following criteria (OR statements) met;

 OR: Encounter: Active pregnancy; CareTracker Satisfier

A submitted claim/encounter contains any one of the following ICD-9 codes identifying an active pregnancy. Table 3 Codes to Identify Pregnancy

Pregnancy V22.0 - V22.2, V23.0 – V23.3, V23.41, V23.49,

V23.5, V23.7, V23.9, V23.81-V23.86, or V23.89  OR: Active diagnosis: Pregnancy;

CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Pregnancy Test field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Pregnancy Test field, OR

o

Medical Records Module > History > Pregnancy Test field, OR

Figure 4 Pregnancy Test Field

o

*Medical Records Module > Progress Notes (Clinical Toolbar) > Other Active Pregnancy fields.

*Note: The name, availability, and location of other fields that identify active pregnancy are based on the template you are using.

 OR: Active diagnosis: End Stage Renal Disease (ESRD); CareTracker Satisfier

o

*Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > End Stage Renal Disease, OR

Figure 5 End Stage Renal Disease Field

*Note: The availability of this field is based on the template you are using.

o

A submitted claim/encounter contains any one of the following ICD-9 codes identifying an ESRD.

Table 4 Codes to Identify ESRD

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Numerator

AND: Physical exam finding: Blood pressure under control (<140/90 mmHg); CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Blood Pressure field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > PE tab > Blood Pressure field, OR

o

Medical Records Module > Vital Signs > Blood Pressure field.

Exclusions

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NQF 0024 - Weight Assessment and Counseling for Children and Adolescents

4 NQF 0024 - Weight Assessment and Counseling for Children and Adolescents

4.1 Overview

Description The percentage of patients 2-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or an

Obstetrician/Gynecologist (OB/GYN) and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

4.2 Population

Criteria

1

Denominator

AND: One or more visit encounter with a Primary Care Physician (PCP) or an Obstetrician/Gynecologist (OB/GYN) during the measurement period; CareTracker Satisfier

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o

*Note: The name, availability, and location of other fields that identify active pregnancy are based on the template you are using. Numerator

AND: Physical exam finding: Body Mass Index (BMI); CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Body Mass Index field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > PE tab > Body Mass Index field, OR

o

Medical Records Module > Vital Signs > Body Mass Index field.

Figure 8 Body Mass Index Field

Note: You must enter the height and weight to calculate and display the BMI in the field

.

AND: One of the following criteria (OR statements) met;

 OR: Communication to patient: Counseling for nutrition; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Nutritional Counseling field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Nutritional Counseling field.

Figure 9 Nutritional Counseling Field

 OR: Communication to patient: Counseling for physical activity; CareTracker Satisfier

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Figure 10 Physical Activity Counseling Field

Exclusions

None.

4.3 Population

Criteria

2

All patients 2 to 11 years of age during the measurement period;;

Denominator

Pregnancy V22.0 - V22.2, V23.0 – V23.3, V23.41,

V23.49, V23.5, V23.7, V23.9, V23.81-V23.86, or V23.89

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o

.

o

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o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Physical Activity Counseling field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Physical Activity Counseling field.

Exclusions

None.

4.4 Population

Criteria

3

Denominator

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o

.

o

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o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Physical Activity Counseling field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Physical Activity Counseling field.

Exclusions

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NQF 0028A - Tobacco Use Assessment

5 NQF 0028A - Tobacco Use Assessment

5.1 Overview

Measure ID NQF 0028A

Description The percentage of patients aged 18 years or older who have been seen for at least two office visits, who were queried about

tobacco use one or more times within 24 months.

5.2 Population

Criteria

Denominator

AND: Two or more visit encounters during the past 24 months; CareTracker Satisfier

Numerator

AND: Patient queried for tobacco use within 24 months; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Tobacco Use field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Tobacco Use field, OR

o

Medical Records Module > History > Tobacco Use field.

Figure 19 Tobacco Use Field

Exclusions

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0028B - Tobacco Cessation Intervention

6 0028B - Tobacco Cessation Intervention

6.1 Overview

Measure ID NQF 0028B

Description The percentage of patients aged 18 years or older who have been seen for at least two office visits, who were queried about

tobacco use one or more times within 24 months.

6.2 Population

Criteria

Denominator

AND: Two or more visit encounters during the past 24 months; CareTracker Satisfier

AND: Patient characteristic: Active tobacco user; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Tobacco Use field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Tobacco Use field, OR

o

Medical Records Module>History> Tobacco Use field.

Figure 20 Tobacco Use Field

Numerator

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0028B - Tobacco Cessation Intervention

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Counseling on tobacco cessation field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Counseling on tobacco cessation field, OR

Figure 21 Counseling on Tobacco Cessation Field

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Rx therapy for tobacco cessation field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Rx therapy for tobacco cessation field, OR

Figure 22 Rx Therapy for Tobacco Cessation Field

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Discussing Smoking and Tobacco Use Cessation Strategies

field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Discussing Smoking and Tobacco Use Cessation Strategies field.

Figure 23 Discussing Smoking and Tobacco Use Cessation Strategies Field

Exclusions

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NQF 0031 - Breast Cancer Screening

7 NQF 0031 - Breast Cancer Screening

7.1 Overview

Description The percentage of women 40–69 years of age who had a mammogram to screen for breast cancer.

7.2 Population

Criteria

All female patients 40 to 69 years of age during the measurement period;

Denominator

AND NOT: Procedure performed: Mastectomy (unilateral or bilateral); CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > PE tab > Mastectomy field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Mastectomy field, OR

o

Medical Records Module > History > Mastectomy field, OR

Figure 24 Mastectomy Field

o

A submitted claim/encounter contains any one of the following CPT codes identifying mastectomy.

Table 8 Codes to Identify Mastectomy

Description CPT

Bilateral Mastectomy 19303-19307 with Modifier .50 (19303-50 - 19307-50)

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NQF 0031 - Breast Cancer Screening

Numerator

AND: Diagnostic performed: Breast cancer screening identified with one of the following sub elements (OR statements);

 OR: Procedure performed: Mammography; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > PE tab > Mammography field, OR

Figure 25 Mammography Field

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Mammography field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > A&P tab > Mammography field, OR

o

Medical Records Module > History > Mammography field, OR

Figure 26 Mammography Field

o

*Medical Records Module > Progress Notes (Clinical Toolbar) > Other Mammography fields.

*Note: The name, availability, and location of other fields that identify mammography are based on the template you are using.

 OR: Imaging result: Mammography; CareTracker Satisfier

Medical Records Module > Results.  OR: Encounter: Mammography;

A submitted claim/encounter contains any one of the following CPT and ICD-9 codes identifying mammography. Table 9 Codes to Identify a Mammogram

Description CPT ICD-9-CM Diagnosis

Mammogram 760 90-76092,

77055-77057 V76.11, or V76.12

Exclusions

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NQF 0032 - Cervical Cancer Screening

8 NQF 0032 - Cervical Cancer Screening

8.1 Description

Description The percentage of women 21-64 years of age who received one or more pap tests to screen for cervical cancer.

8.2 Population

Criteria

All female patients 21 to 64 years of age during the measurement period;

Denominator

AND NOT: Procedure performed: Hysterectomy; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Hysterectomy field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Hysterectomy field, OR

o

Medical Records Module > History > Hysterectomy field, OR

Figure 27 Hysterectomy Field

o

* Medical Records Module > Progress Notes (Clinical Toolbar) > Other Hysterectomy fields, OR

*Note: The name, availability, and location of other fields that identify hysterectomy are based on the template you are using.

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NQF 0032 - Cervical Cancer Screening Table 10 Codes to Identify a Hysterectomy

Hysterectomy 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270,

58275, 58280, 58285, 58290-58294, 58541-58544, 58548, 58550, 58552-58554

Numerator

AND: Diagnostic performed: Cervical cancer screening identified with one of the following sub elements (OR statements);

 OR: Procedure performed: Pap smear; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Pap Smear field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Pap Smear field, OR

o

Medical Records Module > History > Pap Smear field.

Figure 28 Pap Smear Field  OR: Laboratory test result: Pap smear;

Medical Records Module > Results.

 OR: Encounter: Cervical cancer screening; CareTracker Satisfier

A submitted claim/encounter contains any one of the following CPT codes identifying cervical cancer screening. Table 11 Codes to Identify Cervical Cancer Screening

Cervical Cancer Screening 88141-88143, 88147, 88148, 88150,

88152-88155, 88164-8816, 88174, or 88175

Exclusions

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NQF 0033 - Chlamydia Screening for Women

9 NQF 0033 - Chlamydia Screening for Women

9.1 Overview

Description The percentage of women 15-24 years of age who were identified as sexually active and who had at least one test for chlamydia

during the measurement year.

9.2 Population

Criteria

1

All female patients who will reach the ages of 15 through 24 years during the measurement period;

Denominator

 OR: Identified as sexually active; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Sexually Active field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Sexually Active field, OR

o

Medical Records Module > History > Sexually Active field.

Figure 29 Sexually Active Field  OR: Laboratory test ordered: Pregnancy test;

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o

Medical Records Module > History > Pregnancy Test field.

 OR: Laboratory test performed: Pregnancy test; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT codes identifying a pregnancy test performed.

Table 12 Codes to Identify a Pregnancy Test

Description CPT codes

Pregnancy Test 84702-84704, or 81025

 OR: Laboratory test result: Pregnancy test; CareTracker Satisfier

Medical Records Module > Results.  OR: IUD used;

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History tab > Birth Control Device insertion date field, OR

Figure 31 Birth Control Device Insertion Date Field

o

A submitted claim/encounter contains any one of the following CPT codes identifying an IUD inserted or used.

Table 13 Codes to Identify IUD Use

IUD Use 58300

 OR: Active medication: Contraceptives (Example: Junel); CareTracker Satisfier

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Pregnancy V22.0 - V22.2, V23.0 – V23.3, V23.41,

V23.49, V23.5, V23.7, V23.9, V23.81-V23.86, or V23.89

 OR: Active diagnosis: Pregnancy; CareTracker Satisfier

OR: Laboratory test performed: Chlamydia screening; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Test tab > Chlamydia Screening field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Chlamydia Screening field, OR

o

Medical Records Module > History > Chlamydia Screening field, OR

Figure 32 Chlamydia Screening Field

o

A submitted claim/encounter contains any one of the following CPT codes identifying chlamydia screening.

Table 15 Codes to Identify Chlamydia Screening

Chlamydia Screening 86631, 87110, 87270, 87320, 87810

OR: Laboratory test result: Chlamydia screening; CareTracker Satisfier

Exclusions

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Medical Records Module > Medications.

OR: Laboratory test performed: Pregnancy test; CareTracker Satisfier

o

OR: Laboratory test result: Pregnancy test; CareTracker Satisfier

9.3 Population

Criteria

2

Denominator

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o

OR: Laboratory test performed: Pregnancy test; CareTracker Satisfier

o

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o

IUD Use 58300

 OR: Active medication: Contraceptives ((Example: Junel);; CareTracker Satisfier

Medical Records Module > Medications.  OR: Encounter: Active pregnancy;

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o

Medical Records Module > Progress Notes (Clinical Toolbar) > Test tab > Chylmdia Screening field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Chylmdia Screening field, OR

o

Medical Records Module > History > Chylmdia Screening field.

Figure 38 Chylmdia Screening Field

OR: Encounter: Chlymdia screening; CareTracker Satisfier

A submitted claim/encounter contains any one of the following CPT codes identifying chlamydia screening. Table 20 Codes to Identify Chlamydia Screening

Exclusions

OR: Active medication: Retinoid; CareTracker Satisfier

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o

9.4 Population

Criteria

3

Denominator

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o

 OR: Laboratory test performed: Pregnancy test; CareTracker Satisfier

o

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o

IUD Use 58300

 OR: Active medication: Contraceptives (Example: Junel); CareTracker Satisfier

Medical Records Module > Medications.  OR: Encounter: Active pregnancy;

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o

Medical Records Module > Progress Notes (Clinical Toolbar) > Test tab > Chylmdia Screening field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Chylmdia Screening field, OR

o

Medical Records Module > History > Chylmdia Screening field.

Figure 44 Chylmdia Screening Field

OR: Encounter: Chlymdia screening; CareTracker Satisfier

A submitted claim/encounter contains any one of the following CPT codes identifying chlamydia screening. Table 25 Codes to Identify Chlamydia Screening

Exclusions

OR: Active medication: Retinoid; CareTracker Satisfier

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o

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NQF 0034 - Colorectal Cancer Screening

10 NQF 0034 - Colorectal Cancer Screening

10.1 Description

Description The percentage of adults 50–75 years of age who had appropriate screening for colorectal cancer.

10.2 Population Criteria

Denominator

Numerator

 OR: Laboratory test performed: Fecal Occult Blood Testing (FOBT) during the measurement period; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Stool occult blood field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Stool occult blood field, OR

o

Medical Records Module > History > Stool occult blood field.

Figure 46 Stool Occult Blood Field

o

* Medical Records Module > Progress Notes (Clinical Toolbar) > Fecal Occult Blood field, OR

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NQF 0034 - Colorectal Cancer Screening

*Note: The availability and location of the FOBT field is based on the template you are using.

o

FOBT test result in Medical Records module> Results, OR

o

A submitted claim/encounter contains any one of the following CPT or ICD-9 codes identifying FOBT, OR

Table 27 Codes to Identify a FOBT Test

Description CPT ICD-9-CM Diagnosis

FOBT 822 70, 82274 V76.51

 OR: Procedure performed: Flexible sigmoidoscopy during the measurement period or the 4 years prior to the start of the measurement period; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Flexible sigmoidoscopy field, OR

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Flexible sigmoidoscopy field, OR

o

Medical Records Module > History > Flexible sigmoidoscopy field.

Figure 48 Flexible Sigmoidoscopy Field

o

A submitted claim/encounter contains any one of the following CPT codes identifying flexible sigmoidoscopy procedure performed, OR

Table 28 Codes to Flexible Sigmoidoscopy Procedure

Flexible Sigmoidoscopy 45330-45335, 45337-45342, or 45345

 OR: Procedure performed: Double-contrast barium enema during the measurement period or the 4 years prior to the start of the measurement

period;

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Air contrast barium enema field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Air contrast barium enema field, OR

o

Medical Records Module > History > Air contrast barium enema field.

Figure 49 Air Contrast Barium Enema Field

o

A submitted claim/encounter contains any one of the following CPT codes identifying double-contrast barium enema procedure performed,

OR

Table 29 Codes to Identify a Double-Contrast Barium Enema

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NQF 0034 - Colorectal Cancer Screening  OR: Procedure performed: Colonoscopy during the measurement period or the 9 years prior to the start of the measurement period;

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Colonoscopy field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Colonoscopy field, OR

o

Medical Records Module > History > Colonoscopy field.

Figure 50 Colonoscopy Field

o

A submitted claim/encounter contains any one of the following CPT codes identifying colonoscopy, OR

Table 30 Codes to Identify Colonoscopy

Colonoscopy 44388-44394, 44397, 45355,

45378-45387, 45391, or 45392

Exclusions

OR: Procedure performed: Total Colectomy; CareTracker Satisfier

o

Medical Records Module > Progress Notes (Clinical Toolbar) > Quality tab > Colectomy field, OR

o

Medical Records Module > Progress Notes (Clinical Toolbar) > History (or Hx) tab > Colectomy field, OR

o

Medical Records Module > History > Colectomy field, OR

Figure 51 Colectomy Field

o

*Medical Records Module > Progress Notes (Clinical Toolbar) > Other Colectomy fields.

*Note: The name, availability, and location of other fields that identify colectomy are based on the template you are using.

o

A submitted claim/encounter contains any one of the following CPT codes identifying total colectomy.

Table 31 Codes to Identify a Total Colectomy

Total Colectomy 44150-44151, 44155-44157, or

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NQF 0038 - Childhood Immunization Status

11 NQF 0038 - Childhood Immunization Status

11.1 Overview

Description The percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV); one

measles, mumps and rubella (MMR); two H influenza type B (HiB); three hepatitis B (Hep B), one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and two separate combination rates.

11.2 Population Criteria 1

All patients who reach two years during the measurement period;

Denominator

Numerator

AND: Medication administered: Four doses of diphtheria, tetanus, and acellular pertussis (DTaP) vaccinations; CareTracker Satisfier

o

Medical Records Module > Immunizations, OR

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered DTaP vaccination.

Table 32 Codes to Identify DTaP Vaccination

Description CPT/CVX

DTaP Vaccination 90696/130, 90698/120, 90700/20, 90721/50,

or 90723/110

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11.3 Population Criteria 2

Denominator

Numerator

AND: Medication administered: Three doses of Injectable Polio Virus (IPV) vaccinations; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered IPV vaccination.

Table 33 Codes to Identify IPV Vaccination

Description CPT/CVX IPV Vaccination 90713/10, 90696/130, 90698/120, or 90723/110 Exclusions None.

11.4 Population Criteria 3

Denominator

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Numerator

AND: Medication administered: One dose of measles, mumps, and rubella (MMR) vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered MMR vaccination.

Table 34 Codes to Identify MMR Vaccination

Description CPT/CVX MMR Vaccination 90707/3, or 90710/94 Exclusions None.

11.5 Population Criteria 4

Denominator

Numerator

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o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered HiB vaccination.

Table 35 Codes to Identify HiB Vaccination

Description CPT/CVX HiB Vaccination 90645/47, 90646/46, 90647/49, 90648/48, 90720/22, 90748/51, 90698/120, or 90721/50 Exclusions None.

11.6 Population Criteria 5

Denominator

Numerator

AND: Medication administered: Three doses of hepatitis B (HepB) vaccinations; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered HepB vaccination.

Table 36 Codes to Identify HepB Vaccination

HepB Vaccination 90636/104, 90740/44, 90743/43, 90744/8,

90747/44, 90748/51, or 90723/110

(43)

NQF 0038 - Childhood Immunization Status None.

11.7 Population Criteria 6

Denominator

Numerator

AND: Medication administered: One dose of chicken pox (VZV)vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered VZV vaccination.

Table 37 Codes to Identify VZV Vaccination

Description CPT/CVX VZV Vaccination 90396/36, 90716/21, or 90710/94 Exclusions None.

11.8 Population Criteria 7

(44)

Numerator

AND: Medication administered: Four doses of pneumococcal conjugate (PCV) vaccinations; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered PCV vaccination.

Table 38 Codes to Identify PCV Vaccination

Description CPT/CVX PCV Vaccination 90669/100, or 90670/133 Exclusions None.

11.9 Population Criteria 8

Denominator

Numerator

(45)

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered Hep A vaccination.

Table 39 Codes to Identify Hep A Vaccination

Description CPT/CVX Hep A Vaccination 90633/83, 90634/84, or 90636/104 Exclusions None.

11.10 Population Criteria 9

Denominator

Numerator

AND: Medication administered: Two or three doses of rotavirus (RV) vaccinations; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered RV vaccination.

Table 40 Codes to Identify RV Vaccination

RV Vaccination 90680/116, 90681/119

(46)

NQF 0038 - Childhood Immunization Status None.

11.11 Population Criteria 10

Denominator

Numerator

AND: Medication administered: Two doses of influenza (flu) vaccinations; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered influenza vaccination.

Table 41 Codes to Identify Influenza Vaccination

Description CPT/CVX Influenza Vaccination 90470/128, 90655/15, 90657/15, 90660/111, 90662/135, 90663/128, 90664/125, 90666/126, 90668/127 Exclusions None.

11.12 Population Criteria 11

(47)

Numerator

AND: Medication administered: One dose of diphtheria, tetanus, and acellular pertussis (DTaP) vaccinations; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered DTaP vaccination.

Table 42 Codes to Identify DTaP Vaccination

DTaP Vaccination 90696/130, 90698/120, 90700/20, 90721/50,

or 90723/110

AND: Medication administered: One dose of injectable polio virus (IPV) vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered IPV vaccination.

Table 43 Codes to Identify IPV Vaccination

IPV Vaccination 90713/10, 90696/130, 90698/120, or

90723/110

AND: AND: One of the following criteria (OR statements) met;

(48)

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered MMR vaccination.

Table 44 Codes to Identify MMR Vaccination

MMR Vaccination 90707/3, or 90710/94

 OR: Medication administered: One dose of measles vaccination, One dose of mumps vaccination and One dose of rubella vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered measles vaccination, AND

Table 45 Codes to Identify Measles Vaccination

Measles Vaccination 90707/5

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered mumps vaccination, AND

Table 46 Codes to Identify Mumps Vaccination

Mumps Vaccination 90704/7

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered rubella vaccination.

Table 47 Codes to Identify Rubella Vaccination

Rubella Vaccination 90706/6

AND: Medication administered: One dose of haemophilus influenza type B (HiB) vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered HiB vaccination.

Table 48 Codes to Identify HiB Vaccination

HiB Vaccination 90645/47, 90646/46, 90647/49, 90648/48,

(49)

AND: Medication administered: One dose of hepatitis B (HepB) vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered HepB vaccination.

Table 49 Codes to Identify HepB Vaccination

HepB Vaccination 90636/104, 90740/44, 90743/43, 90744/8,

90747/44, 90748/51, or 90723/110

AND: Medication administered: One dose of chicken pox (VZV)vaccination; CareTracker Satisfier

o

A submitted claim/encounter contains any one of the following CPT/CVX codes identifying an administered VZV vaccination.

Table 50 Codes to Identify VZV Vaccination

Description CPT/CVX VZV Vaccination 90396/36, 90716/21, or 90710/94 Exclusions None.

11.13 Population Criteria 12

Denominator