CMS Measure ID: #48
Collection Type: CQM
Reporting Frequency: Once per patient per year
Outcome: No
High Priority: No
NQS Domain: Effective Clinical Care
Measure Age: > 2 years
Instructions
This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. This measure is appropriate for use in the ambulatory setting only and is considered a general screening measure. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
Measure Submission Type:
The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.
Description
Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: No
Decile 0: 0 – 0.31
Decile 1: 0.32 – 32.45
Minimum: 32.46 – 58.06
Decile 3: 58.07 – 74.82
Decile 4: 74.83 – 85.24
Decile 5: 85.25 – 95
Decile 6: 95.01 – 98.38
Decile 7: 98.39 – 99.69
Decile 8: 99.7 – 99.99
Decile 10: 100 – 100
Denominator
All female patients aged 65 years and older with a visit during the measurement period
Denominator Criteria (Eligible Cases):
All female patients aged ≥ 65 years on date of encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, G0402
AND NOT
DENOMINATOR EXCLUSION:
Patient use of hospice services any time during the measurement period: G9693
Numerator
Patients who were assessed for the presence or absence of urinary incontinence within 12 months
Definition:
Urinary Incontinence – Any involuntary leakage of urine
Numerator Options:
Performance Met:
Presence or absence of urinary incontinence assessed (1090F)
OR
Performance Not Met:
Presence or absence of urinary incontinence not assessed, reason not otherwise specified (1090F with 8P)