2020 MIPS Measure #286: Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia

Measure Type High Priority Measure? NQS Domain
Process Yes Patient Safety
Data Submission Method(s)
Registry

Measure 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 or orders for home safety evaluation

Instructions

This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of dementia seen during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Measure Submission:

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Denominator

All patients with a diagnosis of dementia

Denominator Criteria (Eligible Cases):

All patients regardless of age

AND

Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, B20, F01.50, F01.51, F02, F02.80, F02.81, F03.90, F03.91, F05, F10.27, G20, 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): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 96116, 96118, 96119, 96120, 96150, 96151, 96152, 96153, 96154, 96155, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99487, 99489, 99490, 99497, 99498

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

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 or orders for home safety evaluation

Numerator Instructions: Mitigation Recommendations should include a discussion with the patient and their caregiver(s) regarding one or more of the following 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.

Note: 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.

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 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 of medical reason(s) for not providing safety concerns screen OR for not providing recommendations, orders or referrals for positive screen (e.g., patient in palliative care, other medical reason) (G9924)

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)

Stay up to date with the latest news regarding MACRA and MIPS.

The Healthmonix Advisor is a free weekly news source, connecting you to the latest updates in the value-based care industry.