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
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 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, 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, 90834, 90837, 96116, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96164, 96167, 96170, 97161, 97162, 97163, 97164, 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*, 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, 99490, 99497
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
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 Instructions:
Mitigation Recommendations should include a discussion with the patient and their caregiver(s) regarding one or more of the above 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.
The following is a non-exhaustive list of safety concerns in the two domains pertinent to this measure. To meet measure requirements a patient’s medical record must have documentation of being screened on at least one concern from each of the two domains.
Dangerousness to self (patient) or others (caregivers and other individuals)
• Medication misuse
• Physical aggressiveness
• Wandering, including addressing precautions that may include physical measures (e.g., locks, fences or hedges), video surveillance, GPS monitoring and Safe Return programs, personal companions, schedule modifications (e.g., adult day care and day programs), rehabilitative measures, and risk mitigation strategies
• Inability to respond rapidly to crisis/household emergencies
• Financial mismanagement, including being involved in “scams”
• Other concerns raised by patient or their caregiver
Environmental risks
• Home safety risks that could arise from cooking or smoking
• Access to firearms or other weapons
• Access to potentially dangerous chemicals and other materials
• Access to and operation of tools and equipment
• Trip hazards in the home increasing the risk of falling
• Other concerns raised by patient or their caregiver
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)
Rationale
Screening for safety concerns has been identified as a major unmet need of persons with dementia (3). Caregivers may be caught unprepared and unaware of the unpredictability of patients with dementia. Numerous Internet resources are available to help guide and support family and other informal caregivers. Local organizations, such as senior centers, may have adult day care programs that offer socialization opportunities for the patient and a chance to participate in planned and supervised activities designed to promote well-being, such as music and exercise. Support groups for caregivers and patients alike may be offered at senior centers, providing opportunities for each to develop a mutual support system. Some respite for caregivers may be found through these resources; longer term respite services may be available at local nursing homes to provide caregivers with a temporary rest from caregiving, while the person with dementia continues to receive care in a safe environment. A health care provider who is familiar with the scope of challenges that can confront patients and caregivers and is able to provide guidance to supportive resources that reinforce safety is a valuable resource
Clinical Recommendation Statements
The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure:
- “Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse (Category I). Important safety issues in the management of patients with dementia include interventions to decrease the hazards of wandering and recommendations concerning activities such as cooking, driving, hunting, and the operation of hazardous equipment. Caregivers should be referred to available books [and other materials] that provide advice and guidance about maximizing the safety of the environment for patients with dementia…As patients become more impaired, they are likely to require more supervision to remain safe, and safety issues should be addressed as part of every evaluation. Families should be advised about the possibility of accidents due to forgetfulness (e.g., fires while cooking), of difficulties coping with household emergencies, and of the possibility of wandering. Family members should also be advised to determine whether the patient is handling finances appropriately and to consider taking over the paying of bills and other responsibilities. At this stage of the disease [i.e., moderately impaired patients], nearly all patients should not drive.” (1)
For mild to moderate Alzheimer's disease
“Assess for safety risks (e.g., driving, financial management, medication management, home safety risks that could arise from cooking or smoking, potentially dangerous behaviors such as wandering)” (2