CMS Measure ID: #181
Collection Type: CQM
Reporting Frequency: Once per patient per year
High Priority: Yes
NQS Domain: Patient Safety
Measure Age: > 2 years
This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. 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 at the time of the qualifying visit. The documented follow up plan must be related to positive elder maltreatment screening, example: “Patient referred for protective services due to positive elder maltreatment screening.” Cognitively impaired patients are included in the denominator of this measure and need to be screened using an elder maltreatment screening tool.
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 submissions; however, these codes may be submitted for those registries that utilize claims data.
Percentage of patients aged 60 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen
2023 Benchmarks (from 2021 CMS data)
Topped out: Yes
Capped at 7: Yes
Decile 0: 0 – 0.07
Decile 1: 0.08 – 91.99
Minimum: 92 – 98.63
Decile 3: 98.64 – 99.46
Decile 4: 99.47 – 99.99
Decile 10: 100 – 100
All patients aged 60 years and older
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 60 years on date of encounter
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 92002, 92004, 92012, 92014, 92517, 92518, 92519, 92521, 92522, 92523, 92524, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92548, 92549, 92550, 92551*, 92552, 92553, 92555, 92556, 92557, 92558, 92567, 92568, 92570, 92587, 92588, 92610, 92620, 92625, 92626, 92650*, 92651, 92652, 92653, 96105, 96116, 96125, 96130, 96132, 96136, 96138, 96156, 96158, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97802, 97803, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99404*, 99483, 99487, 99490, 99491, 99492, G0101, G0102, G0270, G0402, G0438, G0439
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, FQ, 93
Patients with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of the encounter and follow-up plan documented on the date of the positive screen
Screen for Elder Maltreatment – An elder maltreatment screen should include assessment and documentation of one or more of the following components: (1) physical abuse, (2) emotional or psychological abuse, (3) neglect (active or passive), (4) sexual abuse, (5) abandonment, (6) financial or material exploitation and (7) unwarranted control.
Physical Abuse – Infliction of physical injury by punching, beating, kicking, biting, burning, shaking, or other actions that result in harm.
Emotional/Psychological Abuse – Willful infliction of mental or emotional anguish by threat, humiliation, isolation, or other verbal or nonverbal conduct.
Neglect – Involves attitudes of others or actions caused by others-such as family members, friends, or institutional caregivers-that have an extremely detrimental effect upon well-being.
- Active – Behavior that is willful or when the caregiver intentionally withholds care or necessities. The neglect may be motivated by financial gain or reflect interpersonal conflicts.
- Passive – Situations where the caregiver is unable to fulfill his or her care giving responsibilities as a result of illness, disability, stress, ignorance, lack of maturity, or lack of resources.
Sexual Abuse – Forcing of undesired sexual behavior by one person upon another against their will who are either competent or unable to fully comprehend and/or give consent. This may also be called molestation.
Elder Abandonment – Desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.
Financial or Material Exploitation – Taking advantage of a person for monetary gain or profit.
Unwarranted Control – Controlling a person’s ability to make choices about living situations, household finances, and medical care.
NOTE: Self-neglect is a prevalent form of abuse in the elderly population. Screening for self-neglect is not included in this measure. Resources for suspected self-neglect are listed below.
Follow-Up Plan – Must include a documented report to state or local Adult Protective Services (APS) or the appropriate state agency. Note: APS does not have jurisdiction in all states to investigate maltreatment of patients in long-term care facilities. In those states where APS does not have jurisdiction, APS may refer the provider to another state agency – such as the state facility licensure agency – for appropriate reporting.
Federal reporting: In addition to state requirements, some types of providers are required by federal law to report suspected maltreatment. For example, nursing facilities certified by Medicare and/or Medicaid are required to report suspected maltreatment to the applicable State Survey and Certification Agency.
For state-specific information to report suspected elder maltreatment, including self-neglect, the following resources are available:
- National Adult Protective Services Association – National Adult Protective Services Association Website: http://www.napsa-now.org
- Eldercare Locater – 1-800-677-1116 – Elder Locator Website: https://eldercare.acl.gov/Public/Index.aspx
- National Center on Elder Abuse – National Center on Elder Abuse Website: https://ncea.acl.gov
Disclaimer: The follow-up plan recommendations set forth in this quality measure are not intended to supersede any mandatory state, local or federal reporting requirements.
Not Eligible (Denominator Exception) – A patient is not eligible if one or more of the following reasons is documented:
- Patient refuses to participate and has reasonable decisional capacity for self-protection
- Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
NUMERATOR NOTE: Documentation of an elder maltreatment screening must include identification of the tool used. Examples of screening tools for elder maltreatment include, but are not limited to: Elder Abuse Suspicion Index (EASI), Vulnerability to Abuse Screening Scale (VASS) and Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). These tools are psychometrically sound instruments with demonstrated reliability and validity indices.
Elder maltreatment screen documented as positive AND a follow-up plan is documented (G8733)
Elder maltreatment screen documented as negative, follow-up is not required (G8734)
Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter (G8535)
Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible for follow-up plan at the time of the encounter (G8941)
Performance Not Met:
No documentation of an elder maltreatment screen, reason not given (G8536)
Performance Not Met:
Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given (G8735)