CMS Measure ID: #238
Collection Type: CQM
Reporting Frequency: Once per patient per year
Outcome: No
High Priority: Yes
NQS Domain: Patient Safety
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. 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.
The measure reflects potentially inappropriate medication use in older adults, both for medications where any use is inappropriate and for medications where use under all but specific indications is potentially inappropriate.
This measure will be calculated with 2 performance rates:
1. Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
2. 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.
For accountability reporting in the CMS MIPS program, the rate for submission criteria 1 is used for performance.
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:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. 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.
Description
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: Yes
Capped at 7: No
Decile 0: 20.01 – 100
Decile 1: 3.74 – 20
Minimum: 0.64 – 3.73
Decile 3: 0.06 – 0.63
Decile 4: 0.01 – 0.05
Decile 10: 0 – 0
eCQM
Topped out: Yes
Capped at 7: No
Decile 0: 21.83 – 100
Decile 1: 10.56 – 21.82
Minimum: 6.71 – 10.55
Decile 3: 3.85 – 6.7
Decile 4: 1.8 – 3.84
Decile 5: 0.65 – 1.79
Decile 6: 0.17 – 0.64
Decile 7: 0.01 – 0.16
Decile 10: 0 – 0
Denominator
SUBMISSION CRITERIA 1: PERCENTAGE OF PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS
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 (SUBMISSION CRITERIA 1):
Patients 65 years and older who had a visit during the measurement period
Denominator Criteria:
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSION:
Patients who use hospice services any time during the measurement period: G9741
OR
Patients receiving palliative care during the measurement period: G0034
SUBMISSION CRITERIA 2: 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
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 (SUBMISSION CRITERIA 2):
Patients 65 years and older who had a visit during the measurement period
Denominator Criteria:
Patients aged ≥ 65 years on date of encounter
AND
Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99387*, 99397*, G0438, G0439
AND NOT
DENOMINATOR EXCLUSIONS:
Patients who use hospice services any time during the measurement period: G9741
OR
Patients receiving palliative care during the measurement period: G0034
Numerator
NUMERATOR (SUBMISSION CRITERIA 1):
Patients ordered at least two high-risk medications from the same drug class during the measurement year.
Definitions:
The intent of the measure is to assess if the eligible clinician ordered high-risk medication(s). The intent of the numerator is to assess if the patient has either been ordered:
-
At least two high-risk medications from the same drug class (grouped by row) in Table 1 on different dates of service, or
-
At least two high-risk medications from the same drug class (grouped by row) in Table 2 on different dates of service, where the sum of days supply exceeds 90 days
- At least two high-risk medications from the same drug class in Table 3 on different dates of service, each exceeding average daily dose criteria.
If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the submitting provider also ordered a high-risk medication for them from the same drug class.
Calculate average daily dose for each prescription event. To calculate average daily dose, multiply the quantity of pills prescribed by the dose of each pill and divide by the days supply. For example, a prescription for the 30-days supply of digoxin containing 15 pills, 0.25 mg each pill, has an average daily dose of 0.125 mg. To calculate average daily dose for elixirs and concentrates, multiply the volume prescribed by daily dose and divide by the days supply. Do not round when calculating average daily dose.
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.
For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was ordered again for 60 days with 1 refill for 60 days. The “cumulative medication duration” is (30 x 3) + (60 x 2) = 210 days over the 10 month period.
Table 1 – High-Risk Medications at any dose or duration
|
Description |
Prescription |
|
Anticholinergics, first-generation antihistamines |
Brompheniramine |
|
Anticholinergics, anti-Parkinson agents |
Benztropine (oral) |
|
Antispasmodics |
Atropine (exclude ophthalmic) |
|
Antithrombotics |
Dipyridamole, oral short- acting |
|
Cardiovascular, alpha agonists, central |
Methyldopa |
|
Cardiovascular, other |
Disopyramide |
|
Central nervous system, antidepressants |
Amitriptyline |
|
Central nervous system, barbiturates |
Amobarbital |
|
Central nervous system, vasodilators |
Ergot mesylates |
|
Central nervous system, other |
Meprobamate |
|
Endocrine system, estrogens with or without progestins; include only oral and topical patch products |
Conjugated estrogen |
|
Endocrine system, sulfonylureas, long-duration |
Chlorpropamide |
|
Endocrine system, other |
Desiccated thyroid |
|
Nonbenzodiazepine hypnotics |
Eszopiclon |
|
Pain medications, skeletal muscle relaxants |
Carisoprodol |
|
Pain medications, other |
Indomethacin Meperidine |
*The registry version of the measure specifications only indicates 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 submission.
Table 2 – High-Risk Medications With Days Supply Criteria
|
Description |
Prescription |
Days Supply Criteria |
|
Anti-Infectives, other |
Nitrofurantoin Nitrofurantoin macrocrystals Nitrofurantoin macrocrystals- monohydrate |
>90 days |
Table 3 – High-Risk Medications With Average Daily Dose Criteria
| Prescription | Average Daily Dose Criteria |
| Reserpine | > 0.1 mg per day |
| Digoxin | > 0.125 mg per day |
| Doxepin/Doxepin hydrochloride | > 6 mg per day |
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. Submitting 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
- A prescription for medications classified as high risk exceeding average daily dose criteria listed in Table 3
Numerator Options:
Performance Met: At least two orders for high-risk medications from the same drug class (G9367)
OR
Performance Not Met: At least two orders for high-risk medications from the same drug class not ordered (G9368)
NUMERATOR (SUBMISSION CRITERIA 2):
Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines), except for appropriate diagnoses.
Definitions:
The intent of the numerator is to assess if the patient has been ordered at least two high-risk medications from the same drug class (grouped by row) in Table 4 on different dates or service. The intent of the measure is to assess if the submitting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the submitting provider also ordered a high-risk medication for them from the same drug class.
Index Prescription Start Date (IPSD) – the start date of the earliest prescription ordered for a high-risk medication during the measurement period.
|
Description |
Prescription |
|
Antipsychotics, first (conventional) and second (atypical) generation |
Aripiprazole |
|
Benzodiazepines, long, short and intermediate acting |
Alprazolam |
*The registry version of the measure specifications only indicates 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 submission.
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. Submitting 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 4
Numerator Options:
Performance Met: At least two orders for high-risk medications from the same drug class, (Table 4), without appropriate diagnoses (M1209)
OR
Performance Not Met: At least two orders for high-risk medications from the same drug class, (Table 4), not ordered (M1210)
OR
Performance Not Met: Two or more antipsychotic prescriptions ordered for patients who had 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 (G0032)
OR
Performance Not Met: Two or more benzodiazepine prescriptions ordered for patients who had 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 (G0033)