Quality Registry

This page will explain how to perform the suggested Quality measures for registry-based reporting in TRAKnet. Click here for more information about Quality, and here for more information about MIPS.

NQF 0059: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Measure #001
Details: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.
Denominator Criteria: Diagnoses of Diabetes Mellitus (E10, E11, E13 or O24). age 18-75, E&M.
Numerator Criteria: Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0%.
Performance Met:
3046F HbA1c > 9
3046F w/ modifier 8P not performed
Performance Not Met:
3044F HbA1c < 7
3051F HbA1c 7 – 8
3052F HbA1c 8 - 9
Exclusion (excluded from measure calculations):
G9687 hospice services provided to patient any time during the measurement period
G9988 Palliative care services provided to patient any time during the measurement period.
G2081 Patients age 66 and older in Institutional Special Needs Plans (SNP) Or residing in long-term care with POS code 32, 33, 34, 54 Or 56 for more than 90 consecutive days during the measurement period.
G2090 Patients 66 years of age and older with at least one claim/encounter for frailty during the measurement period and a dispensed medication for dementia durin gthe measurement period Or the year prior to the measurement period.
G2091 Patients 66 years of age and older with at leaste one claim/encounter for frailty during the measurement period and either one acute inpatient encounter with a diagnosis of advanced illness or two outpatient, observation, ED or non-acute inpatient encounters on different dates of service with an advanced illness diagnosis during the measurement period or the year prior to the measurement period.

Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 1:28 of the below tutorial video.

NQF 0326: Care Plan

Measure #047
Details: Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Denominator Criteria: Age 65+, E&M.
Numerator Criteria: Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.
Performance Met:
1123F advance care plan or surrogate decision maker documented in medical record
1124F patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan
Performance Not Met:
1123F w/ modifier 8P not performed
Exclusion (excluded from measure calculations):
G9692 hospice services received by patient any time during the measurement period
Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 3:01 of the below tutorial video.

NQF 0041: Preventative Care and Screening: Influenza Immunization

Measure #110
Details: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.
Denominator Criteria: Age 6+ months, two E&M between October 1 and March 31 excluding telehealth modifiers (GQ, GT) OR one preventative visit E&M between October 1 and March 31 excluding telehealth modifiers (GQ, GT).
Numerator Criteria: Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization.
Performance Met:
G8482 influenza administered or previously recorded
Performance Not Met:
G8484 not administered: No reason
Exception (included in measure calculations but doesn't count against performance rates):
G8483 not administered: Patient allergy or declined
Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 4:46 of the below tutorial video.

NQF 0043: Pneumococcal Vaccination Status for Older Adults

Measure #111
Details: Percentage of patients 66 years of age and older who have ever received a pneumococcal vaccine.
Denominator Criteria: Age 65+, E&M.
Numerator Criteria: Patients who have ever received a pneumococcal vaccination.
Performance Met:
G9991 Pneumonia vaccine administered on or after patient's 60th birthday and before the end of the measurement period.
G9989 Documenation of medical reason(s) for not administering pneumococcal vaccine (e.g. adverse reaction to vaccine).
Performance Not Met:
G9990 Pneumococcal vaccine was not administered on or after patient's 60th birthday and before the end of the measurement period, reason not otherwise specified.
Exclusion (excluded from measure calculations):
G9707 hospice services received by patient any time during the measurement period

Reporting Instructions: This must be done a minimum of once per reporting period.

A tutorial of this measure is found at 6:42 of the below tutorial video.

NQF 0417: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological Evaluation

Measure #126
Details: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months.
Denominator Criteria: Diagnoses of Diabetes Mellitus (E10, E11 or E13), Age 18+, debridement, avulsion or E&M excluding telehealth modifiers (GQ, GT).
Numerator Criteria: Patients who had a lower extremity neurological exam performed at least once within 12 months.
Performance Met:
G8404 lower extremity neurological exam performed and documented
Performance Not Met:
G8405 lower extremity neurological exam not performed
Exclusion (excluded from measure calculations):
G2179 Clinician documented that patient had medical reason for not performing lower extremity neurological exam.

Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 8:26 of the below tutorial video.

NQF 0416: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear

Measure #127
Details: Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing.
Denominator Criteria: Diagnoses of Diabetes Mellitus (E10, E11 or E13), Age 18+, debridement, avulsion or E&M excluding telehealth modifiers (GQ, GT).
Numerator Criteria: Patients who were evaluated for proper footwear and sizing at least once within 12 months.
Performance Met:
G8410 footwear evaluation performed and documented
Performance Not Met:
G8415 footwear evaluation was not performed
Exception (included in measure calculations but doesn't count against performance rates):
G8416 clinician documented that patient was not an eligible candidate for footwear evaluation measure
Exclusion (excluded from measure calculations):
G2180 Clinician documented that patient was not and eligbile candidate for evaluation of footwear as patient is bilateral lower exremity amputee.

Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 10:04 of the below tutorial video.

NQF 0421: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Measure #128
Details: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30 kg/m2; Age 18 – 64 years BMI ≥ 18.5 and < 25 kg/m2.
Denominator Criteria: Age 18+, E&M excluding telehealth modifiers (GQ, GT).
Numerator Criteria: Patients with a documented BMI during the encounter or during the previous six months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter.
Performance Met:
G8420 BMI within normal limits and no follow-up
G8417 BMI above normal limits and follow-up plan made with doctor
G8418 BMI below normal limits and follow-up plan made with doctor
Performance Not Met:
G8421 BMI not documented with no reason given
G8419 BMI outside of normal limits and no follow-up
Exception (included in measure calculations but doesn't count against performance rates):
G9716 not documented for documented reason
G2181 BMI not documented due to medical reason OR patient refusal of height or weight measurement.
Exclusion (excluded from measure calculations):
G9996 Documenation stating the patient has received Or is currently receiving palliative Or hospice care.
G9997 Documenation of patient pregnancy anytime during the measurement period prior to and including the current encounter.

Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 11:48 of the below tutorial video.

NQF 0419: Document Current Medications

Measure #130
Details: Documentation of Current Medications in the Medical Record: Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional)supplements AND must contain the medications’ name, dosage, frequency and route of administration.
Denominator Criteria: Age 18+, E&M.
Numerator Criteria: Eligible professional attests to documenting, updating or reviewing a patient’s current medications using all immediate resources available on the date of encounter. This list must include ALL known prescriptions, over-the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosages, frequency and route of administration.
Performance Met:
G8427 patient medications have been reviewed
Performance Not Met:
G8428 patient medications not documented
Exception (included in measure calculations but doesn't count against performance rates):
G8430 patient not eligible
Reporting Instructions: This must be reported for each visit during the reporting period.

A tutorial of this measure is found at 13:30 of the below tutorial video.

NQF 0028: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Measure #226 Criteria One:
Details: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Denominator Criteria: Age 18+, two E&M OR one preventative visit E&M.
Numerator Criteria: Patients who were screened for tobacco use at least once within the measurement period
Performance Met:
G9902 patient screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user. ATTENTION: Any patient that meets this selection will count as a denominator for Measure #226 Criteria Two.
G9903 Current tobacco non-user
Performance Not Met:
G9905 w/ modifier 8P Patient not Screen for tobacco use, reason not given.
Exception (included in measure calculations but doesn't count against performance rates):
G9904 w/ modifier 1P documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy, other medical reason)

Reporting Instructions: This must be reported once per reporting period.

Measure #226 Criteria Two:
Details: Preventive Care and Screening: Tobacco Use: All patients who were identified as a tobacco user and who received tobacco cessation intervention
Denominator Criteria: Age 18+, two E&M OR one preventative visit E&M who were screen for tobacco use during the measurement period and identified as a tobacco user.
Numerator Criteria: Patients who were screened for tobacco use at least once within the measurement period
Performance Met:
G9906 patient identified as a tobacco user received tobacco cessation intervention (counseling and/or pharmacotherapy)
Performance Not Met:
G9908 Patient identified as tobacco user did not receive tobacco cessation intervention (counseling and/or pharmacotherapy)
Exception (included in measure calculations but doesn't count against performance rates):
G9907 documentation of medical reason(s) for not providing cessation intervention (eg, limited life expectancy, other medical reason)

Reporting Instructions: This must be reported once per reporting period.

Measure #226 Criteria Three:
Details: Preventive Care and Screening: Tobacco Use: All patients who were screened for tobacco use and, if identified as a tobacco user received tobacco cessation intervention, or identified as a tobacco non-user.
Denominator Criteria: Age 18+, two E&M OR one preventative visit E&M.
Numerator Criteria: Patients who were screened for tobacco use at least once within the measurement period
Performance Met:
G0030 Patient screen for tobacco use And received tobacco cessation intervention on the date of the encounter Or within the previous 12 months (counseling pharmacotherapy, or both) if identified as a tobacco user.
1036F Current tobacco non-user
Performance Not Met:
G0028 Tobacco screening not performed OR tobacco cessation intervention not provided on the date of the encounter Or within the previous 12 months' reason Not otherwise specified.
Exception (included in measure calculations but doesn't count against performance rates):
G0028 Documentation of medical reason(s) for not screening for tobacco use (e.g. limited life expectancy, other medical reasons)
G9909 Tobacco screening not performed OR tobacco cessation intervention not provided on the date of the encounter or within the previous 12 months, reason not otherwise specified.

Reporting Instructions: This must be reported once per reporting period.

A tutorial of this measure is found at 17:05 of the below tutorial video.

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

Measure #317
Details: Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated.
Denominator Criteria: Age 18+, E&M excluding telehealth modifiers (GQ, GT).
Numerator Criteria: Patients who were screened for high blood pressure AND have a recommended follow-up plan documented, as indicated, if the blood pressure is pre-hypertensive or hypertensive.
Performance Met:
G8783 Normal blood pressure reading documented, no follow-up required
G8950 pre-Hypertensive or Hypertensive BP reading documented, AND the indicated follow-up is documented
Performance Not Met:
G8785 BP reading not documented, no reason given
G8952 Pre-Hypertensive or Hypertensive BP reading documented, indicated follow-up not documented, reason not given
Exception (included in measure calculations but doesn't count against performance rates):
G9745 screening not performed for documented reason
Exclusion (excluded from measure calculations):
G9744 not eligible due to active diagnosis of hypertension
Reporting Instructions: This measure is to be reported a minimum of once per reporting period. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The documented follow-up plan must be related to the current BP reading as indicated, example: “Patient referred to primary care provider for BP management”.

A tutorial of this measure is found at 18:46 of the below tutorial video.

NQF 0101: Falls: Plan of Care

Measure #155
Details: Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months.
Denominator Criteria: Age 65+, E&M, 1100F CPT code reported in the numerator for Measure #154 (Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year)
Numerator Criteria: Patients with a plan of care for falls documented within 12 months.
Performance Met:
0518F Falls plan of care documented
Performance Not Met:
0518F w/ modifier 8P Plan of care not documented, reason not otherwise specified
Exception (included in measure calculations but doesn't count against performance rates):
0518F w/ modifier 1P Patient not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair
Exclusion (excluded from measure calculations):
G9720 Hospice services for patient occurred any time during the measurement period
Reporting Instructions: This measure is to be reported a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure is appropriate for use in all non-acute settings (excludes emergency departments and acute care hospitals). This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

Quality - Registry Tutorial Video

For more information on how to fulfill each objective in TRAKnet, see the video below:

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