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.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) 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 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, F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, 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, 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, 99242*, 99243*, 99244*, 99245*, 99252*, 99253*, 99254*, 99255*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, 99487, 99490, 99491, 99497
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) and basic activities of daily living (ADL).
Numerator Instructions:
To meet this measure providers must assess BOTH IADL and ADL performance.
1. IADL Assessment (users must meet one of the two below bullets to meet IADL assessment component)
- To meet the measure’s IADL component using a validated tool, providers must use one of the following tools:
- Lawton Instrumental Activities of Daily Living Scale
- Bristol Activities of Daily Living Scale
- Katz Index of Independence in Activities of Daily Living
- Functional Activities Questionnaire
- Functional Independence Measure Instrument
- To meet the measure’s IADL component using a direct assessment, providers must document 3 out of the following 5 domains.
- Cleaning or hobbies,
- Money management,
- Medication management,
- Transportation, and
- Cooking or communication
2. ADL Assessment (users must meet one of the two below bullets to meet ADL assessment component)
- To meet the measure’s ADL component using a validated tool, providers must use either:
- Barthel ADL Index
- Bristol Activities of Daily Living Scale
- To meet the measure’s ADL component using a direct assessment, providers must document 3 out of the following 7 domains.
- Grooming,
- Bathing,
- Dressing,
- Eating,
- Toileting,
- Gait, and
- Transferring.
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 advanced stage dementia and caregiver knowledge is limited (G9917)
OR
Performance Not Met: Functional status not performed, reason not otherwise specified (G9918)
Rationale
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. Unmet Needs of Community-Residing Persons with Dementia and Their Informal Caregivers: Findings from the MIND at Home Study. 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
Perform regular, comprehensive person-centered assessments and timely interim assessments. Assessments, conducted at least every 6 months, should prioritize issues that help the person with dementia to live fully. These include assessments of the individual and care partner’s relationships and subjective experience and assessment of cognition, behavior, and function, using reliable and valid tools. Assessment is ongoing and dynamic, combining nomothetic (norm-based) and idiographic (individualized) approaches. (Molony SL, Kolanowski A, Van Haitsma K, et al. Person-Centered Assessment and Care Planning. The Gerontologist. 2018; 58(1):S32-S47.)