Measure Description
Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months
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 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
All patients with a diagnosis of dementia
DENOMINATOR NOTE: *Signifies that this CPT Category I 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 MIPS CQMs.
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, F02.80, F02.81, F03.90, F03.91, F05, F10.27, 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, 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96150, 96151, 96152, 96153, 96154, 96155, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99251, 99252, 99253, 99254, 99255, 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 for whom an assessment of functional status was performed at least once in the last 12 months
Definition:
Assessment of functional status - Functional status is assessed by use of a validated tool, direct assessment of the patient, or by querying a knowledgeable informant. A direct assessment of functional status includes an evaluation of the patient’s ability to perform instrumental activities of daily living (IADL) (i.e., cleaning, money management, and medication management, transportation, cleaning, and cooking) and basic activities of daily living (ADL) (i.e., grooming, bathing, dressing, eating, toileting, gait, and transferring). Documentation why an assessment could not be completed due to advanced staging of dementia in combination with a lack of a knowledgeable informant would meet the measure criteria.
Numerator Instructions:
Functional status can be assessed by direct examination of the patient or knowledgeable informant. An assessment of functional status should include, at a minimum, an evaluation of the patient’s ability to perform instrumental activities of daily living (IADL) and basic activities of daily living (ADL). Functional status can also be assessed using one of a number of available valid and reliable instruments available from the medical literature. Examples include, but are not limited to:
• Lawton Instrumental Activities of Daily Living Scale
• Barthel ADL Index
• Katz Index of Independence in Activities of Daily Living
• Functional Activities Questionnaire
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. Documentation of advanced stage dementia and caregiver knowledge is limited would meet the measure exception criteria.
Numerator Options:
Performance Met: Functional status performed once in the last 12 months (G9916)
OR
Denominator Exception: Documentation of medical reason(s) for not performing functional status (e.g., patient is severely impaired and caregiver knowledge is limited, other medical reason) (G9917)
OR
Performance Not Met: Functional status not performed, reason not otherwise specified (G9918)
Rationale
Dementia is characterized by cognitive deficits that cause functional impairment compromising basic and instrumental activities of daily living. Functional decline for dementia patients is progressive and continuous and typically marked by decline in instrumental activities of daily living followed by a slower decline in basic activities of daily living. (Lechowski L et al. Dement Geriatr Cogn Disord. 2010; 29(1):46-54.) Functional impairment is the main factor negatively impacting quality of life in patients with dementia including reported links to the development of apathy and depression. (Andersen CK, et al. Health Qual Life Outcomes. 2004, 2:52., Starkstein SE et al. Am J Psychiatry. 2005;162:2086-2093., Boyle PA, et al. Am J Geriatr Psychiatry. 2003 Mar-Apr;11(2): 214-21.) In addition, decline in basic activities of daily living is an important risk factor for institutionalization and a strong predictor of decreased survival in dementia patients. (Steeman E, et al. Arch Psychiatr Nurs. 1997; 11, 295-303., Bracco L, et al. Arch Neurol. 1994 Dec; 51(12): 1213-9.) Initial and ongoing assessments of functional status should be conducted to determine baseline level of functioning, monitor changes over time, and to identify strategies to maximize patient’s independence.
Maintaining or increasing physical functioning levels is a desired outcome. This is key to maintaining quality of life and reducing caregiver burden. This requires regular assessment of function in multiple domains. In routine practice, persons with dementia may not be assessed regularly for changes in their ability to perform both basic and instrumental activities of daily living. (Black BS, Johnston D, Rabins PV, et al. J Am Geriatr Soc 2013;61(12):2087-2095.) Frequent and comprehensive assessments will allow health care providers to track these changes and to make timely interventions aimed at preserving function or mitigating disability. When planning interventions to improve or maintain function, it is important to consider a broad range of causes of functional impairment, including impaired cognition.
Clinical Recommendation Statements
A detailed assessment of functional status may also aid the clinician in documenting and tracking changes over time as well as providing guidance to the patient and caregivers. Functional status is typically described in terms of the patient’s ability to perform instrumental activities of daily living such as shopping, writing checks, basic housework, and activities of daily living such as dressing, bathing, feeding, transferring, and maintaining continence. These regular assessments of recent cognitive and functional status provide a baseline for assessing the effect of any intervention, and they improve the recognition and treatment of acute problems, such as delirium. (APA, 2007)