2023 # MBHR18 Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of Results

Measure Title: Provision of Feedback Following a Cognitive or Mental Status Assessment with Documentation of Understanding of Test Results and Subsequent Healthcare Plan with Timely Transmission of Results

Description: Percentage of patients, regardless of age, who received a standardized cognitive or mental status assessment followed by provision of feedback regarding test results and associated recommendations, who acknowledged understanding of test results and associated recommendations and healthcare plan.

AND

Percentage of patients, regardless of age, for which the referring provider or patient receives reporting of assessment results within 14 days of the completion of feedback.

Denominator: All patients, regardless of age, who were referred for a cognitive or mental health assessment due to concerns about cognitive impairment, and who had an eligible encounter visit during the measurement period. Reported concerns may come from: the patient, a treating provider, or a caregiver of the patient.

AND
Patient encounter during the performance period (CPT):
90791; 96156; 96116; 96121; 96132; 96133; 96146; 96105; 96125; 96110

Numerator: Patients that underwent a standardized cognitive or mental status assessment for whom feedback of test results and associated treatment recommendations was provided to the receiver or their caregiver, with documentation of understanding of test results and associated treatment recommendations/healthcare plan.

Test results may include any of the following types of information:

o Explanation of test results and their implication to everyday function
o Explanation of how test results contribute to determination of diagnosis
o Discussion of factors contributing to identified cognitive difficult
o Discussion of expected prognosis and the impact of treatment recommendations on cognitive, behavioral, and emotional functioning
o Discussion of warning signs for cognitive decline
o Discussion of protective factors against cognitive decline and/or factors that promote healthy cognitive development
o Treatment recommendations provided clearly and in a way that is easily understood. This may include:
o Treatment options.
o Compensatory strategies.
o Referral recommendations for allied and other medical specialties.
o Community resources.
o Safety concerns.
o Caregiver support.
o Lifestyle modifications beneficial for healthy brain aging.
o Receiver acknowledged understanding of the results, recommendations, and subsequent treatment plan during the feedback session.
o Receiver was provided the opportunity to ask questions during the feedback session.

AND

Number of patients who were referred for and completed a standardized cognitive or mental status assessment for whom results were reported back to the patient, referring provider or treatment team within 14 days of provision of feedback.

NUMERATOR NOTE: The 14 day guideline period is defined as 14 days from the date of feedback.

*See definitions below for details
Definitions:

Provider: The clinician that provided the service of the intended measure.

Referral: A request from one eligible provider to another eligible provider for evaluation, treatment, or co-management of a patient’s condition. For this measure, referral indicates referral of a patient for a cognitive or mental status assessment. This term encompasses referral and consultation as defined by Centers for Medicare and Medicaid Services.

Report: A verbal summary or written document provided to the referral source by the provider of the assessment that includes description of the assessment findings, diagnostic information, and/or associated healthcare plan.

Feedback: A feedback session provided by the eligible clinician to the patient and/or caregiver which includes assessment findings, diagnostics, and/or health care plan and other treatment recommendations.

NUMERATOR NOTE:
Resulting report should be completed after the referral was generated and should be related to the referral for which it is attributed. If there are multiple reports regarding a given patient that are generated to the same referral source, use the report which includes provision of feedback to satisfy the measure. The provider to whom the patient was referred should be the same provider that generates and provides the report.

Denominator Exclusions: Death

Denominator Exceptions: Patient presents an acute condition or crisis who are not administered a standardized assessment

OR

Patient refuses to participate in feedback session

OR

Patient is unable to communicate AND does not have a caregiver available to provide information.

OR

Feedback AND/OR report was not provided to patient and/or caregivers under the CURES act Preventing Harm Exception, which states: “It will not be information blocking for an actor to engage in practices that are reasonable and necessary to prevent harm to a patient or another person, provided certain conditions are met.”

OR

Contexts where results reporting to patients is limited or prohibited by organizational policy or law (e.g., some forensic hospitals/jails/etc.).

OR

Patient or provider limitations preclude meeting this timeframe. For example, patient limitations may include, but are not limited to: there is an appreciable change in the patient’s medical and/or cognitive status since the last date of testing which will impact interpretation of results, report delay due to a delay in receiving critical records, etc. Provider limitations may include, but are not limited to: report not sent to referring provider because referring provider no longer open and/or no longer present at that organization, etc.

National Quality Forum (NQF) number, if applicable
N/A

Care setting(s) 
Ambulatory Care: Clinician Office/Clinic; Ambulatory Care: Hospital; Home Care; Hospital; Hospital Inpatient; Hospital Outpatient; Long Term Care; Nursing Home; Outpatient Services; Rehabilitation Facility

Telehealth, if applicable
Yes

Number of performance rates required for measures
1

Traditional vs. inverse measure
Traditional

Proportional, continuous variable, and/or ratio measure indicator
Proportional

Risk adjustment, if applicable
No

Submission pathway 
Traditional MIPS