2023 # 238 Use of High-Risk Medications in Older Adults

CMS Measure ID: #238

Collection Type: CQM, eCQM, MVP

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.

Description

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class

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
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine
Dimenhydrinate
Diphenhydramine (oral)
Doxylamine
Hydroxyzine
Meclizine
Promethazine
Pyrilamine
Triprolidine

Anticholinergics, anti-Parkinson agents

Benztropine (oral)
Trihexyphenidyl

Antispasmodics

Atropine (exclude ophthalmic)
Belladonna alkaloids
Chlordiazepoxide-clidinium
Dicyclomide
Hyoscyamine
Methscopolamine
Propantheline
Scopolamine

Antithrombotics

Dipyridamole, oral short- acting

Cardiovascular, alpha agonists, central

Methyldopa
Guanfacine

Cardiovascular, other

Disopyramide
Nifedipine, immediate release

Central nervous system, antidepressants

Amitriptyline
Clomipramine
Amoxapine
Desipramine
Imipramine
Trimipramine
Nortriptyline
Paroxetine
Protriptyline

Central nervous system, barbiturates

Amobarbital
Butabarbital
Butalbital
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
Estropipate
Estradiol
Esterified estrogen

Endocrine system, sulfonylureas, long- duration

Chlorpropamide
Glimepiride
Glyburide

Endocrine system, other

Desiccated thyroid
Megestrol

Nonbenzodiazepine hypnotics

Eszopiclon
Zaleplon
Zolpidem

Pain medications, skeletal muscle relaxants

Carisoprodol
Chlorzoxazone
Cyclobenzaprine
Metaxalone Methocarbamol
Orphenadrine

Pain medications, other

Indomethacin Meperidine
Ketorolac, includes parenteral

 

*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 3 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
Asenapine
Brexpiprazole
Cariprazine
Chlorpromazine
Clozapine
Fluphenazine
Haloperidol
Iloperidone
Loxapine
Lurasidone
Molindone
Olanzapine
Paliperidone
Perphenazine
Pimavanserin
Pimozide
Quetiapine
Risperidone
Thioridazine
Thiothixene
Trifluoperazine
Ziprasidone

Benzodiazepines, long, short and intermediate acting

Alprazolam
Chlordiazepoxide
Clonazepam
Clorazepate
Diazepam
Estazolam
Flurazepam
Lorazepam
Midazolam
Oxazepam
Quazepam
Temazepam
Triazolam

*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 3

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)

 

 

 


Tags

CQM-2023, CQM-eCQM-2023, CQM-eCQM-MVP-2023, CQM-MVP-2023, ecqm-2023, MVP-2023