Measure Description
Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if symptoms screening was positive, there was also documentation of recommendations for management 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.
NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.
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, 96127, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170*, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99241*, 99242*, 99243*, 99244*, 99245*, 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, 99424, 99426, 99487, 99490, 99497
Numerator
Patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression in the last 12 months and for whom, if screening was positive, there was also documentation of recommendations for management in the last 12 months
Definition:
Behavioral and Psychiatric Symptoms Screening - Screening is defined as using a validated instrument or directly examining the patient or knowledgeable informant to determine the presence or absence of symptoms from three domains: Activity disturbances, mood disturbances (including depression), and thought and perceptional disturbances. The following validated instruments can be used to meet the measure:
- Dementia Signs and Symptoms (DSS) Scale
- Neuropsychiatric Inventory (NPI)
- Minimum Data Set (MDS) (suggested for nursing home only).
Numerator Instructions:
Symptoms Screening for at least one symptom each for three domains of behavioral and psychiatric symptoms, including depression is defined as using a validated instrument or directly examining the patient or knowledgeable informant to determine the presence or absence of symptoms from three domains: activity disturbances, mood disturbances (including depression), and thought and perceptional disturbances. The following is a non-exhaustive list of symptoms falling into each of the three requisite domains pertinent to this measure:
Activity disturbances (To meet measure, patient or knowledgeable informant must be screened for at least one symptom from this list):
- Agitation
- Wandering
- Purposeless hyperactivity
- Verbal or physical aggressiveness
- Resisting care
- Apathy
- Impulsiveness
- Socially inappropriate behaviors
- Eating disturbances
- Sleep problems
- Diurnal/sleep-wake cycle disturbances
- Repetitive behavior
Mood disturbances (To meet measure, patient or knowledgeable informant must be screened for depression and at least one more symptom from this list):
- Anxiety
- Elation
- Irritability
- Mood lability/fluctuations
Thought and perceptual disturbances (To meet measure, patient or knowledgeable informant must be screened for at least one symptom from this list:
- Thought and perceptual disturbances
- Having fixed false beliefs (delusions)
- Hearing or seeing non-present entities (hallucinations)
- Paranoia
Examples of reliable and valid instruments that can be used to assess behavioral and psychiatric symptoms are:
Dementia Signs and Symptoms (DSS) Scale or Neuropsychiatric Inventory (NPI). For patients residing in nursing homes, it may be the Minimum Data Set (MDS). Other reliable and valid instruments may be used to assess individual measure components for activity disturbances, mood disturbances including depression, and thought and perceptual disturbances.
NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. In the event that a patient is not screened or partially screened during an eligible encounter for behavioral and psychiatric symptoms or the screening status is unknown submit G9921.
Numerator Options:
Performance Met: Screening Performed AND Positive AND Provision of Recommendations (G9919)
OR
Performance Met: Screening Performed AND Negative (G9920)
OR
Performance Not Met: No Screening Performed, Partial Screening Performed OR Positive Screen Without Recommendations and Reason is Not Given or Otherwise Specified (G9921)
Rationale
Decreasing the rate of behavioral and psychiatric symptoms of dementia (BPSD) is a desired outcome. These symptoms, including depression, have serious adverse impact on quality of life for patients and caregivers and increase the risk of institutionalization. They may go unrecognized and untreated by health care providers if they are not actively screened for with specific attention to discrete symptom domains.
A report by Kales, et al. from a multidisciplinary expert panel provided recommendations for the spectrum of aggression, agitation, depression, anxiety, delusions, hallucinations, apathy and disinhibition. (Kales HC, Gitlin LN, Lyketsos CG, et al. Management of neuropsychiatric symptoms of dementia in clinical settings: recommendations from a multidisciplinary expert panel. J Am Geriatr Soc. 2014;62(4):762-769.) Regarding specific treatment interventions for BPSD, there have been a number of recent studies examining both pharmacologic and non-pharmacologic methods as well as the effects of antipsychotic discontinuation. (Dyer SM, Harrison SL, Laver K, et al. An overview of systematic reviews of pharmacological and non-pharmacological interventions for the treatment of behavioral and psychological symptoms of dementia Int Psychogeriatr 2018;30(3):295-309; Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of longterm antipsychotic drug use for behavioral and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018;3:CD007726.)
Clinical Recommendation Statements
The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure:
- “It is important for the [clinician] treating a patient with dementia to regularly assess cognitive deficits or behavioral difficulties that potentially pose a danger to the patient or others.” (American Psychiatric Association (APA). Practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Arlington (VA): American Psychiatric Association (APA). October 2007 85 p.5)
- “Traditionally cognitive function has been the main focus of interest in treatment and research of people with dementia. It is becoming increasingly recognized, however, that noncognitive symptoms are those that are most disturbing to families and caregivers and may seriously impact not only the patient’s well-being, but also the family’s, caregiver’ and providers’ approaches to managing the patient”(6Sadowsky CH, Galvin JE. Guidelines for the management of cognitive and behavioral problems in dementia. JABFM 2012;25(3):350-366.)
- “Assess and monitor for behavioral changes; in particular, the presence of agitation, aggression, anxiety, disinhibitions, delusions, and hallucinations” (7Fletcher K. Geriatric Nursing Protocol: Recognition and Management of Dementia. Springer Publishing Company. Evidence-Based Geriatric Nursing Protocols for Best Practice, 4th Edition. August 2012.)
- “Identification of neuropsychiatric symptoms is essential for both the diagnosis and treatment, as some BPSD constitute the core or supportive diagnostic features of some non-AD dementias, such as DLB, PDD or FTLD” (Sorbi S, Hort J, Erkinjuntti T, et al. EFNS-ENS Guidelines on the diagnosis and management of disorders associated with dementia. Eur J Neurol 2012;19(9):1159-1179.8)
- “In summary, new trials and studies better define adverse effects, but they do not strengthen the evidence for efficacy of antipsychotic drugs in treating psychosis or agitation. Rather, they demonstrate minimal or no efficacy with strong placebo effects as well as variations in response with trial duration. These findings strengthen the support for using nonpharmacological interventions and environmental measures to attempt to reduce psychosis and agitation prior to initiation of medications.”(9Rabins PV, Rovner BW, Rummans T, et al. Guideline Watch (October 2014): Practice Guideline For The Treatment Of Patients With Alzheimer's Disease And Other Dementias. American Psychiatric Association. 26 p.)