2017 MIPS Measure #238: Use of High-Risk Medications in the Elderly


Valid Data Submission Method(s) Measure Type High Priority Measure? NQS Domain Specialty Measure Sets
EHR, Registry Process Yes Patient Safety

Measure Description

Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.

Instruction

This measure is to be reported a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

This measure will be calculated with 2 performance rates:

1)Percentage of patients who were ordered at least one high-risk medication

2)Percentage of patients who were ordered at least two different high-risk medications

Eligible clinicians should continue to report the measure as specified, with no additional steps needed to account for multiple performance rates.

Denominator

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:
1.Percentage of patients who were ordered at least one high-risk medication

OR

2.Percentage of patients who were ordered at least two different high-risk medications

 

DENOMINATOR (REPORTING CRITERIA 1):
Patients 66 years and older who had a visit during the measurement period

Denominator Criteria (Eligible Cases) 1:
Patients aged ≥ 66 years on date of encounter
AND
Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Patients who use hospice services any time during the measurement period: G9741

 

–OR–

 

DENOMINATOR (REPORTING CRITERIA 2):
Patients 66 years and older who had a visit during the measurement period

Denominator Criteria (Eligible Cases) 2:
Patients aged ≥ 66 years on date of encounter
AND
Patient encounter during performance period (CPT or HCPCS): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Patients who use hospice services any time during the measurement period: G9741

Numerator

THERE ARE TWO REPORTING CRITERIA FOR THIS MEASURE:
1.Percentage of patients who were ordered at least one high-risk medication

OR

2.Percentage of patients who were ordered at least two different high-risk medications

 

NUMERATOR (REPORTING CRITERIA 1):
Percentage of patients who were ordered at least one high-risk medication during the measurement period

Numerator Instructions:
INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following:
•A prescription for medications classified as high risk at any dose and for any duration listed in Table 1
•Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulativemedication duration listed in Table 2

Definitions:
Cumulative Medication Duration – an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

Table 1 – High-Risk Medications at any dose or duration

       Description                                                    Prescription

 

 

Anticholinergics (excludes TCAs), first-generation antihistamines

  • Brompheniramine Carbinoxamine
  • Chlorpheniramine
  • Clemastine
  • Cyproheptadine
  • Dexbrompheniramine

 
  • Dexchlorpheniramine
  • Diphenhydramine (oral)
  • Doxylamine
  • Hydroxyzine
  • Promethazine
  • Triprolidine

Anticholinergics (excludes TCAs), anti-Parkinson agents

  • Benztropine (oral)
 
  • Trihexyphenidyl

Antithrombotics

  • Dipyridamole, oral
 
  • Ticlopidine extended-release short-acting (does not apply to the combination with aspirin)

Cardiovascular, alpha agonists, central

  • Guanabenz
  • Methyldopa
 
  • Guanfacine

Cardiovascular, other

  • Disopyramide
 
  • Nifedipine, immediate release

Central nervous system, tertiary TCAs

  • Amitriptyline
  • Clomipramine
 
  • Imipramine
  • Trimipramine

Central nervous system, barbiturates

  • Amobarbital
  • Butabarbital
  • Butalbital
  • Mephobarbital
 
  • Pentobarbital
  • Phenobarbital
  • Secobarbital

Central nervous system, vasodilators

  • Ergot mesylates
 
  • Isoxsuprine

Central nervous system, other

  • Thioridazine
  • Chloral Hydrate
 
  • Meprobamate

Endocrine system, estrogens with or without progestins; include only oral and topical patch products

  • Conjugated estrogen
  • Estropipate
 
  • Estradiol
  • Esterified estrogen

Endocrine system, sulfonylureas, long- duration

  • Chlorpropamide
 
  • Glyburide

Endocrine system, other

  • Desiccated thyroid
 
  • Megestrol

Gastrointestinal system, other

  • Trimethobenzamide

 

 

Pain medications, skeletal muscle relaxants

  • Carisoprodol
  • Chlorzoxazone
  • Cyclobenzaprine
 
  • Metaxalone
  • Methocarbamol
  • Orphenadrine

Description

Prescription

 

 

Pain medications, other

  • Indomethacin
  • Meperidine
 
  • Ketorolac, includes parenteral Pentazocine

Table 2 – High-Risk Medications With Days Supply Criteria

 

Description

 

 Prescription

 

 

 Prescription

Days

Supply

Criteria

Anti-Infectives, other

 
  • Nitrofurantoin
  • Nitrofurantoin macrocrystals

 

 
  • Nitrofurantoin macrocrystals- monohydrate

>90 days

Nonbenzodiazepine hypnotics

 
  • Eszopiclone
  • Zaleplon

 

 
  • Zolpidem

>90 days

NUMERATOR NOTE: Some high-risk medications are not included in this specific measure but should be avoided above a specified average daily dose. These medications are listed in table DAE-C. To calculate an average daily dose multiply the quantity of pills ordered by the dose of each pill and divide by the days supply. For example, a prescription for a 30-days supply of digoxin containing 15 pills, 0.250 mg each pill, has an average daily dose of 1.125 mg.

Table 4 – DAE-C: High-Risk Medications With Average Daily Dose Criteria

Description

Prescription

Average Daily Dose Criteria

Alpha agonists, central

  • Reserpine

>0.1 mg/day

Cardiovascular, other

  • Digoxin

>0.125 mg/day

Tertiary TCAs (as single agent or as part of combination products)

  • Doexpin

>6 mg/day

Numerator Options:
Performance Met: One high-risk medication ordered (G9365)
OR
Performance Not Met: One high-risk medication not ordered (G9366)

 

–OR–

 

NUMERATOR (REPORTING CRITERIA 2):
Percentage of patients who were ordered at least two different high-risk medications during the measurement period

Numerator Instructions:
INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Reporting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following:

  • A prescription for medications classified as high risk at any dose and for any duration listed in Table 1
  • Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulative

medication duration listed in Table 2

Definitions:
Cumulative Medication Duration – an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

Table 5 – High-Risk Medications at any dose or duration

Description                 Prescription

 

 

Anticholinergics (excludes TCAs), first-generation antihistamines

  • Brompheniramine Carbinoxamine
  • Chlorpheniramine
  • Clemastine

 
  • Dexchlorpheniramine
  • Diphenhydramine (oral)
  • Doxylamine
  • Hydroxyzine

 

  • Cyproheptadine
 
  • Promethazine

 

  • Dexbrompheniramine
  • Meclizine
 
  • Triprolidine

Anticholinergics, anti-Parkinson agents

  • Benztropine (oral)
 
  • Trihexyphenidyl

Antithrombotics

  • Dipyridamole, oral short- acting (does not apply to the extended-release combination with aspirin)
 
  • Ticlopidine

Cardiovascular, alpha agonists, central

  • Guanabenz
  • Guanfacine
 
  • Methyldopa

Cardiovascular, other

  • Disopyramide
 
  • Nifedipine, immediate release

Description

Prescription

 

 

Central nervous system, antidepressants

  • Amitriptyline
  • Clomipramine
  • Amoxapine
  • Desipramine
  • Nortriptyline
  • Paroxetine
  • Protriptyline
 
  • Imipramine
  • Trimipramine

Central nervous system, barbiturates

  • Amobarbital
  • Butabarbital
  • Butalbital
  • Mephobarbital
 
  • Pentobarbital
  • Phenobarbital
  • Secobarbital

Central nervous system, vasodilators

  • Ergot mesylates
 
  • Isoxsuprine

Central nervous system, other

  • Meprobamate

 

 

Endocrine system, estrogens with or without progestins; include only oral and topical patch products

  • Conjugated estrogen
  • Esterified estrogen
 
  • Estradiol
  • Estropipate

Description

Prescription

 

 

Endocrine system, sulfonylureas, long- duration

  • Chlorpropamide
 
  • Glyburide

Endocrine system, other

  • Desiccated thyroid
 
  • Megestrol

Pain medications, skeletal muscle relaxants

  • Carisoprodol
  • Chlorzoxazone
  • Cyclobenzaprine
 
  • Metaxalone
  • Methocarbamol
  • Orphenadrine

Pain medications, other

  • Indomethacin
  • Ketorolac, includes parenteral
 
  • Meperidine
  • Pentazocine

*The registry version of the measure specifications only indicate the classes of drugs that are considered high-risk and do not include the specific coding of RxNorm. However, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for reporting.

Table 6 – High-Risk Medications With Days Supply Criteria

 

Description

 

Prescription

 

 

Days

Supply

Criteria

Anti-Infectives, other

  • Nitrofurantoin
  • Nitrofurantoin macrocrystals
 
  • Nitrofurantoin macrocrystals- monohydrate

>90 days

Nonbenzodiazepine hypnotics

  • Eszopiclone Zaleplon

 

 
  • Zolpidem

>90 days

NUMERATOR NOTE: Some high-risk medications are not included in this specific measure but should be avoided above a specified average daily dose. These medications are listed in table DAE-C. To calculate an average daily dose multiply the quantity of pills ordered by the dose of each pill and divide by the days supply. For example, a prescription for a 30-days supply of digoxin containing 15 pills, 0.250 mg each pill, has an average daily dose of 0.125 mg.

Table 7 – DAE-C: High-Risk Medications With Average Daily Dose Criteria

Description

Prescription

Average Daily Dose Criteria

Alpha agonists, central

  • Reserpine

>0.1 mg/day

Cardiovascular, other

  • Digoxin

>0.125 mg/day

Tertiary TCAs (as single agent or as part of combination products)

  • Doxepin

>6 mg/day

Numerator Options:
Performance Met: At least two different high-risk medications ordered (G9367)
OR
Performance Not Met: At least two different high-risk medications not ordered (G9368)

Stay up to date with the latest news regarding MACRA and MIPS.

The Healthmonix Advisor is a free weekly news source, connecting you to the latest updates in the value-based care industry.