MIPS CLINICAL QUALITY MEASURES (CQMS)
Description:
Percentage of patients aged 18 years and older with two or more diagnoses of rheumatoid arthritis (RA) at least 90 days apart who have an assessment of disease activity using an ACR-preferred RA disease activity assessment tool at ≥50% of encounters for RA for each patient during the performance period.
Instructions:
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of RA seen during the performance period. 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 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:
Patients aged 18 years and older with two or more RA diagnoses documented at least 90 days apart with at least one encounter with an RA diagnosis occurring during the performance period and an additional encounter with an RA diagnosis occurring in the performance period or prior performance period
Definitions:
Encounter – An encounter during the performance period where one of the CPT or HCPCS codes listed in the patient encounter criteria is used without a telehealth modifier (i.e., only non-telehealth visits are to be considered for this measure).
Additional encounter – An additional encounter during the performance period or prior performance period where one of the CPT or HCPCS codes listed in the patient encounter is used to confirm an RA diagnosis with ICD-10-CM diagnosis codes as listed in the Denominator criteria.
DENOMINATOR NOTE: *Signifies that this HCPCS 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 the MIPS CQMs.
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
AND
Diagnosis for rheumatoid arthritis (RA) (ICD-10-CM): M05.00, M05.011, M05.012, M05.019, M05.021, M05.022, M05.029, M05.031, M05.032, M05.039, M05.041, M05.042, M05.049, M05.051, M05.052, M05.059, M05.061, M05.062, M05.069, M05.071, M05.072, M05.079, M05.09, M05.10, M05.111, M05.112, M05.119, M05.121, M05.122, M05.129, M05.131, M05.132, M05.139, M05.141, M05.142, M05.149, M05.151, M05.152, M05.159, M05.161, M05.162, M05.169, M05.171, M05.172, M05.179, M05.19, M05.20, M05.211, M05.212, M05.219, M05.221, M05.222, M05.229, M05.231, M05.232, M05.239, M05.241, M05.242, M05.249, M05.251, M05.252, M05.259, M05.261, M05.262, M05.269, M05.271, M05.272, M05.279, M05.29, M05.30, M05.311, M05.312, M05.319, M05.321, M05.322, M05.329, M05.331, M05.332, M05.339, M05.341, M05.342, M05.349, M05.351, M05.352, M05.359, M05.361, M05.362, M05.369, M05.371, M05.372, M05.379, M05.39, M05.40, M05.411, M05.412, M05.419, M05.421, M05.422, M05.429, M05.431, M05.432, M05.439, M05.441, M05.442, M05.449, M05.451, M05.452, M05.459, M05.461, M05.462, M05.469, M05.471, M05.472, M05.479, M05.49, M05.50, M05.511, M05.512, M05.519, M05.521, M05.522, M05.529, M05.531, M05.532, M05.539, M05.541, M05.542, M05.549, M05.551, M05.552, M05.559, M05.561, M05.562, M05.569, M05.571, M05.572, M05.579, M05.59, M05.60, M05.611, M05.612, M05.619, M05.621, M05.622, M05.629, M05.631, M05.632, M05.639, M05.641, M05.642, M05.649, M05.651, M05.652, M05.659, M05.661, M05.662, M05.669, M05.671, M05.672, M05.679, M05.69, M05.7A, M05.70, M05.711, M05.712, M05.719, M05.721, M05.722, M05.729, M05.731, M05.732, M05.739, M05.741, M05.742, M05.749, M05.751, M05.752, M05.759, M05.761, M05.762, M05.769, M05.771, M05.772, M05.779, M05.79, M05.8A, M05.80, M05.811, M05.812, M05.819, M05.821, M05.822, M05.829, M05.831, M05.832, M05.839, M05.841, M05.842, M05.849, M05.851, M05.852, M05.859, M05.861, M05.862, M05.869, M05.871, M05.872, M05.879, M05.89, M05.9, M06.0A, M06.00, M06.011, M06.012, M06.019, M06.021, M06.022, M06.029, M06.031, M06.032, M06.039, M06.041, M06.042, M06.049, M06.051, M06.052, M06.059, M06.061, M06.062, M06.069, M06.071, M06.072, M06.079, M06.08, M06.09, M06.20, M06.211, M06.212, M06.219, M06.221, M06.222, M06.229, M06.231, M06.232, M06.239, M06.241, M06.242, M06.249, M06.251, M06.252, M06.259, M06.261, M06.262, M06.269, M06.271, M06.272, M06.279, M06.28, M06.29, M06.30, M06.311, M06.312, M06.319, M06.321, M06.322, M06.329, M06.331, M06.332, M06.339, M06.341, M06.342, M06.349, M06.351, M06.352, M06.359, M06.361, M06.362, M06.369, M06.371, M06.372, M06.379, M06.38, M06.39, M06.8A, M06.80, M06.811, M06.812, M06.819, M06.821, M06.822, M06.829, M06.831, M06.832, M06.839, M06.841, M06.842, M06.849, M06.851, M06.852, M06.859, M06.861, M06.862, M06.869, M06.871, M06.872, M06.879, M06.88, M06.89, M06.9
AND
Patient encounter during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, G0402, G0468*
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10
AND
An additional encounter with an RA diagnosis during the performance period or prior performance period that is at least 90 days before or after an encounter with an RA diagnosis during the performance period: M1374
Numerator:
Patients with disease activity assessed using an ACR-preferred rheumatoid arthritis disease activity measurement tool at ≥50% of total number of outpatient RA encounters in the performance period
Definition:
Assessment of Disease Activity – Assesses if physicians are utilizing a standardized, systematic approach for evaluating the level of disease activity for each patient at least for ≥50% of total number of outpatient RA encounters. The scales/instruments listed are the ACR-preferred tools that should be used:
-Clinical Disease Activity Index (CDAI)
-Disease Activity Score with 28-joint counts (erythrocyte sedimentation rate or C-reactive protein) (DAS-28)
-Patient Activity Score-II (PAS-II)
-Routine Assessment of Patient Index Data with 3 measures (RAPID 3)
-Simplified Disease Activity Index (SDAI)
A result within the valid range of the selected tool qualifies for meeting numerator performance as long as a result is captured at ≥50% of each patient’s qualified encounters. If the result of a recorded disease activity assessment is outside the valid range of scores for the tool (e.g., a CDAI score of 101 when the maximum possible score is 76.0) or is only recorded as a disease activity level (e.g., low, moderate, or high) in place of a calculated numerical score, this score should not be included in the count to meet the ≥50% requirement in the numerator.
Numerator Options:
Performance Met: ≥50% of total number of a patient’s outpatient RA encounters assessed (M1007)
OR
Performance Not Met: Disease activity not assessed, reason not given (M1006)
OR
Performance Not Met: <50% of total number of a patient’s outpatient RA encounters assessed (M1008)
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