2026 #286 MIPS Measure Safety Concern Screening and Follow-Up for Patients with Dementia

‌2026 COLLECTION TYPE:

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Process – High Priority

‌DESCRIPTION:

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.

‌INSTRUCTIONS:

‌Reporting Frequency:

This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.

‌Intent and Clinician Applicability:

This measure is intended to reflect the quality of services provided for patients with dementia. 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.

‌Measure Strata and Performance Rates:

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate.

‌Implementation Considerations:

For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once.

‌Telehealth:

TELEHEALTH ELIGIBLE: This measure is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

‌DENOMINATOR:

All patients with dementia.

‌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):

All patients regardless of age

AND

Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F10.27, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94

AND

Patient encounter during the performance period (CPT or HCPCS): 78811, 78814, 90791, 90792, 90832, 90834, 90837, 92507, 92508, 92523, 92526, 92610, 92611, 92612, 92616, 96105, 96112, 96116, 96125, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170*, 97129, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99242*, 99243*, 99244*, 99245*, 99252*, 99253*, 99254*, 99255*, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, 99487, 99490, 99491, 99497, A9586, A9601, Q9982, Q9983

‌NUMERATOR:

Patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources.

‌Definitions:

Caregiver(s) – Person(s) who provide care to those who need supervision or assistance in illness or disability. They may provide the care in the home, in a hospital, or in an institution. Although “caregiver(s)” include trained medical, nursing, and other health personnel, the concept also refers to parents, spouses, or other family members, friends, members of the clergy, teachers, social workers, fellow patients.

Safety Concerns – “Safety concerns” include, but are not limited to:

• Fall risk
• Gait/balance
• Medication management
• Financial management
• Home safety risks that could arise from cooking or smoking
• Physical aggression posing threat to self, family caregiver, or others
• Wandering
• Access to firearms or other weapons
• Access to potentially dangerous materials
• Being left alone in home or locked in room
• Inability to respond rapidly to crisis/household emergencies
• Driving
• Operation of hazardous equipment
• Suicidality
• Abuse or neglect

‌Numerator Instructions:

Mitigation Recommendations should include a discussion with the patient and their caregiver(s) regarding one or more of the above common safety concerns and potential risks to the patient. When appropriate, it should also include a mitigation recommendation or referral or orders for a home safety evaluation.

For nursing home patients, different safety concerns might apply.

A number of organizations have developed educational materials that are recommended to aid implementation of the measure. These materials/tools include:

• Alzheimer’s Association Safety Topics. Available on the Alzheimer’s Association website. Alzheimer’s Disease Education and Referral Center’s Home Safety for the Alzheimer’s Patient Available on the National Institute on Aging website.

The following is a non-exhaustive list of safety concerns in the two domains pertinent to this measure. To meet measure requirements a patient’s medical record must have documentation of being screened on at least one concern from each of the two domains.

Dangerousness to self (patient) or others (caregivers and other individuals)

• Medication misuse
• Physical aggressiveness
• Wandering, including addressing precautions that may include physical measures (e.g., locks, fences or hedges), video surveillance, GPS monitoring and Safe Return programs, personal companions, schedule modifications (e.g., adult day care and day programs), rehabilitative measures, and risk mitigation strategies
• Inability to respond rapidly to crisis/household emergencies
• Financial mismanagement, including being involved in “scams”
• Other concerns raised by patient or their caregiver

Environmental risks

• Home safety risks that could arise from cooking or smoking
• Access to firearms or other weapons
• Access to potentially dangerous chemicals and other materials
• Access to and operation of tools and equipment
• Trip hazards in the home increasing the risk of falling
• Other concerns raised by patient or their caregiver

‌NUMERATOR NOTE:

The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Denominator Exception(s) are determined on the date of the denominator eligible encounter.

‌Numerator Options:

‌Performance Met: Safety concerns screen provided and if positive then documented mitigation recommendations (G9922)

‌OR

Performance Met: Safety concerns screen provided and negative (G9923)

OR

‌Denominator Exception: Documentation patient unable to communicate and informant not available (G2183)

OR

‌Performance Not Met: Safety concerns screening not provided, reason not otherwise specified (G9925)

OR

‌Performance Not Met: Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources (G9926)

RATIONALE:

The assessment of safety is an identified gap in dementia care (Black BS, Johnston D, Rabins PV, et al. Unmet Needs of Community-Residing Persons with Dementia and Their Informal Caregivers: Findings from the MIND at Home Study. J Am Geriatr Soc 2013;61(12):2087-2095.) Persons with dementia are at increased risk of having safety concerns for several reasons. Cognitive loss can lead to confusion regarding use of medications, handling of weapons or machinery, or the ability to remember to turn off appliances, such as ranges and stoves. Dementia also impairs the person’s judgment, and as such, increases the risk for financial abuse and exploitation. The risk of falls among persons with dementia is greater, and following injury, persons with dementia are less likely to recover than other seniors (Allan LM, Ballard CG, Rowan EN, Kenny RA. Incidence and prediction of falls in dementia: a prospective study in older people. PLoS ONE. 2009;4). Persons with dementia are at greater risk of burns due to hot water. Similarly, persons with dementia may exhibit aggressive behaviors towards themselves or others (Salzman C, Jeste D, Meyer RE, CohenMansfield j, et.al. Elderly Patients with Dementia-Related Symptoms of Severe Agitation and Aggression: Consensus Statement on Treatment Options, Clinical Trials, Methodology and Policy. J Clin Psychiatry 2008 June:69(6):889-898). These and other types of injuries are preventable through mitigating strategies, however, the risks must be identified. This quality measure requires screening for safety concerns in two risk domains: dangerousness to self/others and environment. Current treatment guidelines for the management of dementia recommend that healthcare providers screen for safety risks. There are community and online resources to facilitate home safety (Alzheimer’s Association. Home Safety. Available at: https://www.alz.org/help-support/caregiving/safety/home-safety. Accessed November 25, 2018). By routinely screening for safety issues, the clinician will also become increasingly more familiar with the range of problems identified, and thus be able to continuously improve the quality of care delivered.