2024 MIPS Measure #495: Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood

2024 COLLECTION TYPE:

MIPS Clinical Quality Measures (CQMS)

‌MEASURE TYPE: P‌atient-Reported Outcome-Based Performance Measure (PRO-PM) – High Priority

Description

The percentage of top-box responses among patients aged 18 years and older who had an ambulatory palliative care visit and report feeling heard and understood by their palliative care clinician and team within 2 months (60 days) of the ambulatory palliative care visit.

‌Instructions

This measure is to be submitted a minimum of once per performance period for patients that have an ambulatory palliative care visit during the reporting period. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible palliative care providers and clinicians who provide denominator-eligible services will submit this measure. All valid Feeling Heard and Understood (HU) survey results (as defined in the specification) should be included in the aggregate score. The survey tool and recommended survey administration procedures are found in the appendix of American Academy of Hospice and Palliative Medicine’s Implementation Guide- https://aahpm.org/uploads/AAHPM22_PRO-PM_IMPLEMENTATION_GUIDE.pdf. Although the implementation guide recommends a survey vendor, this is not required for MIPS reporting.

• For MIPS eligible individual clinicians, a minimum of 12 HU surveys would need to be received in order to submit this measure.
• For MIPS eligible groups, subgroups*, virtual groups, and APM entities, a minimum of 38 HU surveys would need to be received in order to submit this measure.
• If the MIPS eligible clinician, group, subgroup*, virtual group, and APM entity encompasses multiple sites/locations, each site/location would need to meet the HU survey requirements as stated.

*Subgroups are only available through MVP reporting. All measure-specific criteria must be met by the subgroup.

This measure will be calculated with 4 performance rates:

1. Top-box response to Q1- “I felt heard and understood by this provider and team.”
2. Top-box response to Q2- “I felt this provider and team put my best interests first when making recommendations about my care.”
3. Top-box response to Q3- “I felt this provider and team saw me as a person, not just someone with a medical problem.”
4. Top-box response to Q4- “I felt this provider and team understood what is important to me in my life.”

Submission of all 4 performance rates is required for this measure. For accountability reporting in the CMS MIPS program, a weighted average will be used.

‌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. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator (For All Submissions Criteria):

All patients aged 18 years and older who had an ambulatory palliative care visit between January 1 – October 31

DENOMINATOR NOTE: The same denominator is used for all submission criteria within this quality measure. This measure has two specific pathways to be considered denominator eligible. Patients may be denominator eligible based on a diagnosis of palliative care and an encounter (as indicated below) OR an encounter (as listed below) along with the Hospice and Palliative Care Specialty Code 17.

Denominator Criteria (Eligible Cases):

Patients aged 18 years and older on date of encounter

AND

Diagnosis for palliative care (ICD-10-CM): Z51.5

OR

Patient encounter during the performance period with Hospice and Palliative Care Specialty Code 17: M1365

AND

Patient encounter during the performance period (CPT): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

OR

Patient encounter during the performance period with place of service code 11

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02, POS 10

Denominator Exclusions:

Patients who did not complete at least one of the four patient experience HU survey items and return the HU survey within 60 days of the ambulatory palliative care visit: M1252

OR

Patients who respond on the patient experience HU survey that they did not receive care by the listed ambulatory palliative care provider in the last 60 days (disavowal): M1253

OR

Patients who were deceased when the HU survey reached them: M1254

OR

Patients for whom a proxy completed the entire HU survey on their behalf for any reason (no patient involvement): M1251

Numerator

The Feeling Heard and Understood survey is calculated using top-box scoring within 2 months (60 days) of the ambulatory palliative care visit

Definition: 

Top-box score – The most positive response available within the HU survey. In this instance, respondents must provide the response of “Completely True” which contributes to overall performance of the measure.

Numerator Instructions:

The performance of this measure is based on a multi-item HU survey consisting of 4 questions:

• Q1- “I felt heard and understood by this provider and team.”
• Q2- “I felt this provider and team put my best interests first when making recommendations about my care.”
• Q3- “I felt this provider and team saw me as a person, not just someone with a medical problem.”
• Q4- “I felt this provider and team understood what is important to me in my life.”

For all four questions in this measure, the top box numerator is the number of respondents who answer “Completely true.” An individual’s score can be considered an average of the four top-box responses. Individual scores are combined to calculate an average score for an overall palliative care clinician or group.

Numerator (Submission Criteria 1):

Patient felt heard and understood by this provider and team

Numerator Options:

Performance Met: Patient responded as “completely true” for the question of patient felt heard and understood by this provider and team (M1250)

OR

Denominator Exception: Patient did not respond to the question of patient felt heard and understood by this provider and team (M1239)

OR

Performance Not Met: Patient provided a response other than “completely true” for the question of patient felt heard and understood by this provider and team (M1243)

Numerator (Submission Criteria 2):

Patient felt this provider and team put my best interests first when making recommendations about my care

Numerator Options:

Performance Met: Patient responded “completely true” for the question of patient felt this provider and team put my best interests first when making recommendations about my care (M1247)

OR

Denominator Exception: Patient did not respond to the question of patient felt this provider and team put my best interests first when making recommendations about my care (M1240)

OR

Performance Not Met: Patient provided a response other than “completely true” for the question of patient felt this provider and team put my best interests first when making recommendations about my care (M1244)

Numerator (Submission Criteria 3):

Patient felt this provider and team saw me as a person, not just someone with a medical problem

Numerator Options:

Performance Met: Patient responded “completely true” for the question of patient felt this provider and team saw me as a person, not just someone with a medical problem (M1248)

OR

Denominator Exception: Patient did not respond to the question of patient felt this provider and team saw me as a person, not just someone with a medical problem (M1241)

OR

Performance Not Met: Patient provided a response other than “completely true” for the question of patient felt this provider and team saw me as a person, not just someone with a medical problem (M1245)

Numerator (Submission Criteria 4):

Patient felt this provider and team understood what is important to me in my life

Numerator Options:

Performance Met: Patient responded “completely true” for the question of patient felt this provider and team understood what is important to me in my life (M1249)

OR

Denominator Exception: Patient did not respond to the question of patient felt this provider and team understood what is important to me in my life (M1242)

OR

Performance Not Met: Patient provided a response other than “completely true” for the question of patient felt this provider and team understood what is important to me in my life (M1246)