Measure Title: Trauma Screening and Re-Traumatization Prevention
Description: Adult patients (18 years of age or older) included in the denominator have been screened for a history of life-time trauma exposure using a systematic screening method during a 12-month measurement period AND if positive (e.g., patient endorses being exposed to trauma) the patient is screened for current symptoms of PTSD.
Instructions:
This measure is to be submitted once per performance period for patients seen during the performance period. This measure is intended to reflect systematic screening for a history of trauma. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment Systems (MIPS) eligible clinicians who perform the quality measure based on the services provided and the measure-specific denominator coding. For the purposes of this measure, the most recent denominator eligible encounter should be used to determine if the numerator action for the submission criteria was performed within the 12-month look back period.
Note: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with 95 or POS 02) are allowable.
Denominator:Patients aged 18 years or older on date of encounter AND CPT: 0362T, 0373T, 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 96110, 96112, 96113, 96116, 96121, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96159, 96164, 96165, 96167, 96170, 96171, 96178, 97129, 97130, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99307, 99308 , 99308, 99310, 99354, 99355, 99406, 99407, 99408, 99409, 99446, 99447, 99448, 99449, 99484, 99492, 99493, 99494, G2011, G2061, G2062, G2063, G0396, G0397, G0402, G0438, G0439-
Numerator:
Adult patients (18 years of age or older) included in the denominator have been screened for a history of life-time trauma exposure using a systematic screening method during a 12-month measurement period. If positive (e.g., patient endorses being exposed to trauma), then the patient is screened for current symptoms of PTSD using the PC-PTSD-5 or PCL-5.
Definitions:
Systematic screening method- For the purpose of this measure, one of the following systematic methods to screen for a lifetime history of trauma must be utilized. Systematic screening methods for trauma include:
• Trauma History Screen (THS) (score >1 yes)
• The Brief Trauma Questionnaire (BTQ) (score >1 yes)
• Life Events Checklist for DSM-5 (LEC-5) (score >1 “Happened to Me”)
• Diagnostic and/or Clinical Interview Screening – inquiry about experience and/or witnessing a traumatic event within the resident’s lifetime (score = yes / no)
Numerator Options:
• Performance Met
o All patients/residents get screened for a history of trauma
? No history of trauma reported – Performance Met
? YES, history of trauma –> follow-up with PCL-5, etc. – Performance Met
• Performance Not Met
o Patients/residents not screened for trauma history during reporting period – Performance Not Met
o Patient/residents screen for trauma history, with a positive trauma history –> no follow-up with PCL-5/screening for PTSD – Performance Not Met
Denominator exclusions:
• Patients who die
OR
• Are unable to complete the trauma screening due to cognitive deficit, communication deficit, or language barrier,
OR
• Patient declines to disclose their trauma status
OR
• Unable to assess due to urgent situation
Denominator exceptions: none
Numerator exclusions: none
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; Rehabilitation Facility: Inpatient
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
MVP, Traditional MIPS
