Measure Description
Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred.
Instructions
This measure is to be submitted a minimum of once per performance period for the first referral for all patients during the measurement period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure for the patients for whom a referral was made during the measurement period based on the services provided and the measure-specific denominator coding. The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure. All MIPS eligible clinicians reporting on this measure should note that all data for the reporting year is to be submitted by the deadline established by CMS, however, only first referrals made between January 1 - October 31 (the measurement period) will count towards the denominator to allow adequate time for the referring clinician to collect the consult report by the end of the performance period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinicians, it ensures that the communication loop is closed in a timely manner and that the data is included in the submission to CMS.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.
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
Number of patients, regardless of age, who had an encounter during the performance period and were referred by one clinician to another clinician on or before October 31
DENOMINATOR NOTE: If there are multiple referrals for a patient during the measurement period, use the first referral.
*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):
Patients regardless of age on the date of the encounter
AND
Patient encounter during the performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 90791, 90792, 90839, 96112, 96116, 96136, 96138, 96156, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99381*, 99382*, 99383*, 99384*, 99385*, 99386*, 99387*, 99391*, 99392*, 99393*, 99394*, 99395*, 99396*, 99397*
Patient was referred to another clinician or specialist during the measurement period: G9968
Numerator
Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred
Definitions:
Referral – A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses “referral” and consultation as defined by Centers for Medicare & Medicaid Services.
Report – A written document prepared by the eligible clinician (and staff) to whom the patient was referred and that accounts for their findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, or states the patient did not attend the appointment, and is provided to the referring eligible clinician.
NUMERATOR NOTE: The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure.
The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure.
Numerator Options:
Performance Met: Clinician who referred the patient to another clinician received a report from the clinician to whom the patient was referred (G9969)
OR
Performance Not Met: Clinician who referred the patient to another clinician did not receive a report from the clinician to whom the patient was referred (G9970)
Rationale
Problems in the outpatient referral and consultation process have been documented, including inadequate care pathways between specialty and primary care. Studies suggest that both specialists and primary care providers (PCPs) are not satisfied with current processes [1,2]. Breakdowns in referral communication lead to worse health outcomes, increased cost, and appointment delays [3,4]. A 2018 analysis of primary care referrals to specialists found that of the 103,737 referral scheduling attempts analyzed, only 36,072 (34.8%) resulted in documented complete appointments, defined by the specialty clinician providing report to the PCP after the referral visit [3].
Technological and process-based updates can improve the referral loop process and increase rates of closing the referral loop. Ramelson et. al (2018) enhanced an EHR's Referral Manager module to meet the Controlled Risk Insurance Company’s best practice steps and the requirements of both the CMS EHR Incentive Program and the National Committee for Quality Assurance Patient-Centered Medical Home program. Following the updates, 76.8% of referrals were completed and all defined referral process steps were easier to accomplish [5]. Odisho et. al (2020) developed a referrals automation software to simplify the fax to referral process. Feedback from key stakeholder interviews noted that the software enhanced the referrals process by further streamlining and organizing the patient referral process [4].The Institute for Healthcare Improvement and the National Patient Safety Foundation (2017) reviewed the referrals process in the ambulatory care setting and found that organizational leaders, EHR vendors, regulatory agencies, clinicians, and patients all all play a role in creating a referrals system that is effective, safe, convenient, and patient-centered [1].
References:
- Institute for Healthcare Improvement / National Patient Safety Foundation. (2017). Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era. Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era | IHI - Institute for Healthcare Improvement
- Greenwood-Lee, J., Jewett, L., Woodhouse, L., & Marshall, D. A. (2018). A categorisation of problems and solutions to improve patient referrals from primary to specialty care. BMC health services research, 18(1), 986. https://doi.org/10.1186/s12913-018-3745-y
- Patel, M. P., Schettini, P., O'Leary, C. P., Bosworth, H. B., Anderson, J. B., & Shah, K. P. (2018). Closing the Referral Loop: an Analysis of Primary Care Referrals to Specialists in a Large Health System. Journal of general internal medicine, 33(5), 715–721. https://doi.org/10.1007/s11606-018-4392-z
- Odisho, A. Y., Lui, H., Yerramsetty, R., Bautista, F., Gleason, N., Martin, E., Young, J. J., Blum, M., & Neinstein, A. B. (2020). Design and development of referrals automation, a SMART on FHIR solution to improve patient access to specialty care. JAMIA open, 3(3), 405–412. https://doi.org/10.1093/jamiaopen/ooaa036
- Ramelson, H., Nederlof, A., Karmiy, S., Neri, P., Kiernan, D., Krishnamurthy, R., Allen, A., & Bates, D. W. (2018). Closing the loop with an enhanced referral management system. Journal of the American Medical Informatics Association: JAMIA, 25(6), 715–721. https://doi.org/10.1093/jamia/ocy004
Clinical Recommendation Statements
None