Form CMS-10276 2008 PQRI Measure Specifications

2008 Physician Quality Reporting Initiative
Specifications Document
This document contains the complete specifications for the 119 measures that make up the 2008 Physician
Quality Reporting Initiative (PQRI). Each measure is assigned a unique number. Measure numbers for 2008
PQRI represent a continuation in numbering from the 2007 PQRI Measures 1 through 74. Gaps in measure
numbering reflect those 2007 PQRI measures that are not included for implementation in 2008 PQRI. In
general, the quality measures consist of a numerator and a denominator that permit the calculation of the
percentage of a defined patient population that receive a particular process of care or achieve a particular
outcome. These specifications will be updated prior to the beginning of the 2008 PQRI reporting period to reflect
any additional edits.
The denominator population is defined by certain ICD-9 and CPT Category I codes specified in the measure
that are submitted by eligible professionals as part of a claim for covered services under the Medicare Physician
Fee Schedule. Some measure coding specifications are adapted as needed for implementation in PQRI in
agreement with the measure developer. For example, CPT codes for non-covered services such as preventive
visits are not included in the denominator. If the specified denominator codes for a measure are not included in
the patient’s claim as submitted, then the patient does not fall into the denominator population, and the PQRI
measure does not apply to the patient.
If the patient does fall into the denominator population, the applicable CPT Category II code (or temporary Gcode, where CPT Category II codes are not yet available) that defines the numerator should be submitted.
Where a patient falls in the denominator population but specifications define circumstances in which a patient
may be excluded from the measure’s denominator population, CPT Category II code modifiers such as 1P, 2P,
or 3P are available to describe medical, patient, system, or other reasons for such exclusion. Where the
performance exclusion does not apply, a measure-specific CPT Category II modifier 8P or HCPCS G-code may
be used to indicate that the process of care was not provided for a reason not otherwise specified.
To successfully report quality data for a measure under the PQRI program, it is necessary in all circumstances
to report numerator coding (CPT Category II code and/or G-code), with or without an applicable CPT Category II
code modifier (1P, 2P, 3P, or 8P). Instructions specific to each measure provide additional reporting information.
Instructions for some measures limit the frequency of reporting necessary in certain circumstances, such as for
patients with chronic illness for whom a particular process of care is provided only periodically.
The measure specifications are organized to provide the following information:
• Measure title
• Measure description
• Instructions on reporting including frequency, timeframes, and applicability
• Numerator coding
• Definitions of terms
• Coding instructions
• Use of CPT Category II exclusion modifiers, where applicable
• Denominator coding
• Rationale statement for measure
• Clinical recommendations or evidence forming the basis or supporting criteria for the measure

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2008 PQRI Measure Specifications
Table of Contents
Measure
Number
1
2
3
4
5
6
7
8
9
10
11
12
14
18
19
20
21
22
23
24
28
30
31
32
33
34
35
36
39
40
41

Measure Title

Page

Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus
High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus
Screening for Future Fall Risk
Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin
Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)
Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery Disease
Beta-blocker Therapy for Coronary Artery Disease Patients with Prior Myocardial
Infarction (MI)
Heart Failure: Beta-blocker Therapy for Left Ventricular Systolic Dysfunction
Antidepressant Medication During Acute Phase for Patients with New Episode of
Major Depression
Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic
Resonance Imaging (MRI) Reports
Stroke and Stroke Rehabilitation: Carotid Imaging Reports
Primary Open Angle Glaucoma: Optic Nerve Evaluation
Age-Related Macular Degeneration: Dilated Macular Examination
Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema
and Level of Severity of Retinopathy
Diabetic Retinopathy: Communication with the Physician Managing Ongoing
Diabetes Care
Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second
Generation Cephalosporin
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Non-Cardiac
Procedures)
Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated
in ALL Patients)
Osteoporosis: Communication with the Physician Managing Ongoing Care PostFracture
Aspirin at Arrival for Acute Myocardial Infarction (AMI)
Perioperative Care: Timing of Prophylactic Antibiotics – Administering Physician
Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT) for
Ischemic Stroke or Intracranial Hemorrhage
Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy
Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for Atrial
Fibrillation at Discharge
Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA) Considered
Stroke and Stroke Rehabilitation: Screening for Dysphagia
Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services
Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
Osteoporosis: Management Following Fracture
Osteoporosis: Pharmacologic Therapy

1
3
5
8
10
14
17
20
22
25
28
31
33
35
37
40
45
50
55
60
63
65
68
70
72
74
77
80
82
85
89

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2008 PQRI Measure Specifications
Table of Contents
Measure
Measure Title
Number
43
Use of Internal Mammary Artery (IMA) in Coronary Artery Bypass Graft (CABG)
Surgery
44
Preoperative Beta-blocker in Patients with Isolated Coronary Artery Bypass Graft
(CABG) Surgery
45
Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac Procedures)
46
Medication Reconciliation
47
Advance Care Plan
48
Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65
Years and Older
49
Characterization of Urinary Incontinence in Women Aged 65 Years and Older
50
Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
51
Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
52
Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy
53
Asthma: Pharmacologic Therapy
54
Electrocardiogram Performed for Non-Traumatic Chest Pain
55
Electrocardiogram Performed for Syncope
56
Vital Signs for Community-Acquired Bacterial Pneumonia
57
Assessment of Oxygen Saturation for Community-Acquired Bacterial Pneumonia
58
Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
59
Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
64
Asthma Assessment
65
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
66
Appropriate Testing for Children with Pharyngitis
67
Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline Cytogenetic
Testing Performed on Bone Marrow
68
Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in Patients
Receiving Erythropoietin Therapy
69
Multiple Myeloma: Treatment with Bisphosphonates
70
Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
71
Hormonal Therapy for Stage IC - III ER/PR Positive Breast Cancer
72
Chemotherapy for Stage III Colon Cancer Patients
73
Plan for Chemotherapy Documented Before Chemotherapy Administered
74
Radiation Therapy Recommended for Invasive Breast Cancer Patients who have
Undergone Breast Conserving Surgery
75
Prevention of Ventilator-Associated Pneumonia – Head Elevation
76
Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central Venous
Catheter Insertion Protocol
77
Assessment of GERD Symptoms in Patients Receiving Chronic Medication for
GERD
78
Vascular Access for Patients Undergoing Hemodialysis
79
Influenza Vaccination in Patients with End Stage Renal Disease (ESRD)
80
Plan of Care for ESRD Patients with Anemia
81
Plan of Care for Inadequate Hemodialysis in ESRD Patients

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94
96
99
102
105
107
109
111
113
116
119
121
123
125
127
129
132
134
136
139
142
145
147
149
154
158
160
162
165
167
170
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Table of Contents
Measure
Number
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116

Measure Title

Page

Plan of Care for Inadequate Peritoneal Dialysis
Testing of Patients with Chronic Hepatitis C (HCV) for Hepatitis C Viremia
Initial Hepatitis C RNA Testing
HCV Genotype Testing Prior to Therapy
Consideration for Antiviral Therapy in HCV Patients
HCV RNA Testing at Week 12 of Therapy
Hepatitis A and B Vaccination in Patients with HCV
Counseling Patients with HCV Regarding Use of Alcohol
Counseling of Patients Regarding Use of Contraception Prior to Starting Antiviral
Therapy
Acute Otitis Externa (AOE): Topical Therapy
Acute Otitis Externa (AOE): Pain Assessment
Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of
Inappropriate Use
Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of Tympanic
Membrane Mobility
Otitis Media with Effusion (OME): Hearing Testing
Otitis Media with Effusion (OME): Antihistamines or Decongestants – Avoidance of
Inappropriate Use
Otitis Media with Effusion (OME): Systemic Antimicrobials – Avoidance of
Inappropriate Use
Otitis Media with Effusion (OME): Systemic Corticosteroids – Avoidance of
Inappropriate Use
Breast Cancer Patients who have a pT and pN Category and Histologic Grade for
Their Cancer
Colorectal Cancer Patients who have a pT and pN Category and Histologic Grade
for Their Cancer
Appropriate Initial Evaluation of Patients with Prostate Cancer
Inappropriate Use of Bone Scan for Staging Low-Risk Prostate Cancer Patients
Review of Treatment Options in Patients with Clinically Localized Prostate Cancer
Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients
Three-dimensional Radiotherapy for Patients with Prostate Cancer
Patients who have Major Depression Disorder who meet DSM IV Criteria
Patients who have Major Depression Disorder who are Assessed for Suicide Risks
Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
Patients with Osteoarthritis who have an Assessment of Their Pain and Function
Influenza Vaccination for Patients ≥ 50 Years Old
Pneumonia Vaccination for Patients 65 years and Older
Screening Mammography
Colorectal Cancer Screening
Inquiry Regarding Tobacco Use
Advising Smokers to Quit
Inappropriate Antibiotic Treatment for Adults with Acute Bronchitis

181
184
187
190
193
195
198
201
203
206
208
210
212
214
216
218
220
222
225
228
230
233
236
239
241
245
248
251
253
255
258
261
264
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2008 PQRI Measure Specifications
Table of Contents
Measure
Measure Title
Number
117
Dilated Eye Exam in Diabetic Patient
118
Angiotensin Converting Enzyme Inhibitor (ACE) or Angiotensin Receptor Blocker
(ARB) Therapy for Patients with Coronary Artery Disease and Diabetes and/or Left
Ventricular Systolic Dysfunction (LVSV)
119
Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic
Patients
120
ACE Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy in Patients with CKD
121
Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus, Intact
Parathyroid Hormone (iPTH) and Lipid Profile)
122
Chronic Kidney Disease (CKD): Blood Pressure Management
123
Chronic Kidney Disease (CKD): Plan of Care: Elevated Hemoglobin for Patients
Receiving Erythropoiesis - Stimulating Agents (ESA)
124
HIT- Adoption/Use of Health Information Technology (Electronic Health Records)
125
HIT- Adoption/Use of e-Prescribing
126
Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation
127
Diabetic Foot and Ankle Care, Ulcer Prevention: Evaluation of Footwear
128
Universal Weight Screening and Follow-Up
129
Universal Influenza Vaccine Screening and Counseling
130
Universal Documentation and Verification of Current Medications in the Medical
Record
131
Pain Assessment Prior to Initiation of Patient Treatment
132
Patient Co-Development of Treatment Plan/Plan of Care
133
Screening for Cognitive Impairment
134
Screening for Clinical Depression
Symbol and Copyright Information
List of Retired PQRI Measures

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304
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311
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321
325
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Measure #1: Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent
hemoglobin A1c greater than 9.0%
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
The most recent quality code submitted will be used for performance calculation. This measure
may be reported by clinicians who perform the quality actions described in the measure based on
the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or
G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified.
NUMERATOR:
Patients with most recent hemoglobin A1c level > 9.0%
Numerator Instructions: This is a poor control measure. A lower rate indicates better
performance (e.g., low rates of poor control indicate better care)
Numerator Coding:
Most Recent Hemoglobin A1c Level > 9.0%
CPT II 3046F: Most recent hemoglobin A1c level > 9.0%
OR

OR

If patient is not eligible for this measure because hemoglobin A1c not performed,
report:
Hemoglobin A1c not Performed
Append a reporting modifier (8P) to CPT Category II code 3046F to report circumstances
when the patient is not eligible for the measure.
• 8P: Hemoglobin A1c level was not performed during the performance period (12
months)
Most Recent Hemoglobin A1c Level ≤ 9.0%
CPT II 3044F: Most recent hemoglobin A1c (HbA1c) level < 7.0%
OR
CPT II 3045F: Most recent hemoglobin A1c (HbA1c) level 7.0 to 9.0%

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DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
Denominator Coding:
An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00,
648.01, 648.02, 648.03, 648.04
AND
CPT E/M service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204,
99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Intensive therapy of glycosylated hemoglobin (A1c) reduces the risk of microvascular
complications.
CLINICAL RECOMMENDATION STATEMENTS:
A glycosylated hemoglobin should be performed during an initial assessment and during follow-up
assessments, which should occur at no longer than three-month intervals. (AACE/ACE)
The A1c should be universally adopted as the primary method of assessment of glycemic control.
On the basis of data from multiple interventional trials, the target for attainment of glycemic control
should be A1c values ≤6.5%. (AACE/ACE)
Obtain a glycosylated hemoglobin during an initial assessment and then routinely as part of
continuing care. In the absence of well-controlled studies that suggest a definite testing protocol,
expert opinion recommends glycosylated hemoglobin be obtained at least twice a year in patients
who are meeting treatment goals and who have stable glycemic control and more frequently
(quarterly assessment) in patients whose therapy was changed or who are not meeting glycemic
goals. (Level of evidence: E) (ADA)
Because different assays can give varying glycated hemoglobin values, the ADA recommends that
laboratories only use assay methods that are certified as traceable to the Diabetes Control and
Complications Trial A1c reference method. The ADA’s goal for glycemic control is A1c <7%. (Level
of evidence: B) (ADA)
Monitor and treat hyperglycemia, with a target A1c of 7%, but less stringent goals for therapy may
be appropriate once patient preferences, diabetes severity, life expectancy and functional status
have been considered. (AGS)

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Measure #2: Low Density Lipoprotein Control in Type 1 or 2 Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent LDLC level in control (less than 100 mg/dl)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
The most recent quality code submitted will be used for performance calculation. This measure
may be reported by clinicians who perform the quality actions described in the measure based on
the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or
G-codes, and the appropriate CPT Category II code OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified.
NUMERATOR:
Patients with most recent LDL-C < 100 mg/dL

OR

OR

Numerator Coding:
Most Recent LDL-C Level < 100 mg/dL
CPT II 3048F: Most recent LDL-C < 100 mg/dL
If patient is not eligible for this measure because LDL-C level not performed, report:
LDL-C Level not Performed
Append a reporting modifier (8P) to CPT Category II code 3048F to report circumstances
when the patient is not eligible for the measure.
• 8P: LDL-C was not performed during the performance period (12 months)
Most Recent LDL-C Level ≥ 100 mg/dL
CPT II 3049F: Most recent LDL-C 100-129 mg/dL
OR
CPT II 3050F: Most recent LDL-C ≥ 130 mg/dL

DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes

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Denominator Coding:
An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00,
648.01, 648.02, 648.03, 648.04
AND
CPT E/M service codes or G-codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204,
99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Persons with diabetes are at increased risk for coronary heart disease (CHD). Lowering serum
cholesterol levels can reduce the risk for CHD events.
CLINICAL RECOMMENDATION STATEMENTS:
A fasting lipid profile should be obtained during an initial assessment, each follow-up assessment,
and annually as part of the cardiac-cerebrovascular-peripheral vascular module. (AACE/ACE)
A fasting lipid profile should be obtained as part of an initial assessment. Adult patients with
diabetes should be tested annually for lipid disorders with fasting serum cholesterol, triglycerides,
HDL cholesterol, and calculated LDL cholesterol measurements. If values fall in lower-risk levels,
assessments may be repeated every two years. (Level of evidence: E) (ADA)
Patients who do not achieve lipid goals with lifestyle modifications require pharmacological therapy.
Lowering LDL cholesterol with a statin is associated with a reduction in cardiovascular events.
(Level of evidence: A)
Lipid-lowering therapy should be used for secondary prevention of cardiovascular mortality and
morbidity for all patients with known coronary artery disease and type 2 diabetes. (ACP)
Statins should be used for primary prevention against macrovascular complications in patients with
type 2 diabetes and other cardiovascular risk factors.
Once lipid-lowering therapy is initiated, patients with type 2 diabetes mellitus should be taking at
least moderate doses of a statin.
Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction,
therefore monitor and treat hypertension and dyslipidemias. (AGS)

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Measure #3: High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus
DESCRIPTION:
Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent blood
pressure in control (less than 140/80 mmHg)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. The performance period for this measure is 12 months.
The most recent quality code submitted will be used for performance calculation. This measure
may be reported by clinicians who perform the quality actions described in the measure based on
the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes or
G-codes, and the appropriate CPT Category II codes OR the CPT Category II code with the
modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified.
NUMERATOR:
Patients whose most recent blood pressure < 140/80 mmHg
Numerator Instructions: To describe both systolic and diastolic blood pressure values,
two CPT II codes must be reported – 1) One to describe the systolic value; AND
2) One to describe the diastolic value. If there are multiple blood pressures on the same
date of service, use the lowest systolic and lowest diastolic blood pressure on that date as
the representative blood pressure.
Numerator Coding:
Most Recent Blood Pressure Measurement Performed
Systolic codes (Select one (1) code from this section):
CPT II 3074F: Most recent systolic blood pressure < 130 mmHg
OR
CPT II 3075F: Most recent systolic blood pressure 130 - 139 mmHg
OR
CPT II 3077F: Most recent systolic blood pressure greater than or equal to 140 mmHg
AND
Diastolic code (Select one (1) code from this section):
CPT II 3078F: Most recent diastolic blood pressure less than 80 mmHg
OR

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OR

CPT II 3079F: Most recent diastolic blood pressure 80 - 89 mmHg
OR
CPT II 3080F: Most recent diastolic blood pressure greater than or equal to 90 mmHg
If patient is not eligible for this measure because blood pressure measurement not
performed, report 2000F-8P:
Blood Pressure Measurement not Performed
Append a reporting modifier (8P) to CPT Category II code 2000F to report circumstances
when the patient is not eligible for the measure.
• 8P: No documentation of blood pressure measurement

DENOMINATOR:
Patients aged 18 through 75 years with the diagnosis of diabetes
Denominator Coding:
An ICD-9 diagnosis code for diabetes and a CPT E/M service code or G-code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 648.00,
648.01, 648.02, 648.03, 648.04
AND
CPT E/M service codes: 97802, 97803, 97804, 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350, G0270, G0271
RATIONALE:
Intensive control of blood pressure in patients with diabetes reduces diabetes complications,
diabetes-related deaths, strokes, heart failure, and microvascular complications.
CLINICAL RECOMMENDATION STATEMENTS:
Recommends that a blood pressure determination during the initial evaluation, including orthostatic
evaluation, be included in the initial and every interim physical examination. (AACE/ACE)
Blood pressure control must be a priority in the management of persons with hypertension and
type 2 diabetes. (ACP)
Blood pressure should be measured at every routine diabetes visit. Patients found to have systolic
blood pressure >130 mmHg or diastolic >80 mmHg should have blood pressure confirmed on a
separate day. Orthostatic measurement of blood pressure should be performed to assess for the
presence of autonomic neuropathy. (Level of Evidence: E) (ADA)
Older persons with diabetes are likely to benefit greatly from cardiovascular risk reduction,
therefore monitor and treat hypertension and dyslipidemias. (AGS)

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Measurement of blood pressure in the standing position is indicated periodically, especially in
those at risk for postural hypotension. At least two measurements should be made and the average
recorded. After BP is at goal and stable, follow-up visits can usually be at 3- to 6-month intervals.
Comorbidities such as heart failure, associated diseases such as diabetes, and the need for
laboratory tests influence the frequency of visits. (JNC)
All individuals should be evaluated during health encounters to determine whether they are at
increased risk of having or of developing chronic kidney disease. This evaluation of risk factors
should include blood pressure measurement. (NKF)

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Measure #4: Screening for Future Fall Risk
DESCRIPTION:
Percentage of patients aged 65 years and older who were screened for future fall risk (patients are
considered at risk for future falls if they have had 2 or more falls in the past year or any fall with
injury in the past year) at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure is appropriate
for use in all non-acute settings (excludes emergency departments and acute care hospitals). This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
CPT codes and patient demographics (age, gender, etc.) are used to identify patients who are
included in the measure’s denominator. CPT Category II codes are used to report the numerator of
the measure.
When reporting the measure, submit the listed CPT codes and the appropriate CPT Category II
code OR the CPT Category II code with the modifier. The modifiers allowed for this measure are:
1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were screened for future fall risk (patients are considered at risk for future falls if they
have had 2 or more falls in the past year or any fall with injury in the past year) at least once within
12 months
Numerator Instructions: Patients are considered at risk for future falls if they have had 2
or more falls in the past year or any fall with injury in the past year
Definition: A fall is defined as a sudden, unintentional change in position causing an
individual to land at a lower level, on an object, the floor, or the ground, other than as a
consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external
force (Tinetti).
Numerator Coding:
Screening for Future Fall Risk Performed
CPT II 1100F: Patient screened for future fall risk; documentation of two or more falls in
the past year or any fall with injury in the past year
OR
CPT II 1101F: Patient screened for future fall risk; documentation of no falls in the past
year or only one fall without injury in the past year
OR

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OR

Screening for Future Fall Risk not Performed for Medical Reasons
Append a modifier (1P) to CPT Category II code 1100F or 1101F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not screening for future fall risk (e.g.,
patient is not ambulatory)
Screening for Future Fall Risk not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1100F to report circumstances
when an action described in a measure’s numerator is not performed and the reason is not
otherwise specified.
• 8P: Patient was not screened for future fall risk, reason not otherwise specified

DENOMINATOR:
All patients aged 65 years and older
Denominator Coding:
A CPT code is required to identify patients for denominator inclusion.
CPT codes: 97001, 97002, 97003, 97004, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325,
99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350
RATIONALE:
Patients may not volunteer information regarding falls.
CLINICAL RECOMMENDATION STATEMENTS:
All older persons who are under the care of a health professional (or their caregivers) should be
asked at least once a year about falls. (AGS/BGS/AAOS)
Older persons who present for medical attention because of a fall, report recurrent falls in the past
year, or demonstrate abnormalities of gait and/or balance should have a fall evaluation performed.
This evaluation should be performed by a clinician with appropriate skills and experience, which
may necessitate referral to a specialist (e.g., geriatrician). (AGS/BGS/AAOS)
Older people in contact with health care professionals should be asked routinely whether they have
fallen in the past year and asked about the frequency, context and characteristics of the falls.
(NICE) (Grade C)
Older people reporting a fall or considered at risk of falling should be observed for balance and gait
deficits and considered for their ability to benefit from interventions to improve strength and
balance. (NICE) (Grade C)

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Measure #5: Heart Failure: Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction
(LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure and left ventricular
systolic dysfunction (LVSD) who were prescribed ACE inhibitor or ARB therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all heart failure patients
seen during the reporting period. This measure is intended to reflect the quality of services
provided for patients with heart failure and decreased left ventricular systolic function. The left
ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which
may be current or historical. Examples of a quantitative or qualitative assessment may include an
echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that
uses descriptive terms such as moderately or severely depressed left ventricular dysfunction. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
ACE Inhibitor or ARB Therapy Prescribed
(Two CPT II codes [4009F & 3021F] are required on the claim form to submit this
category)
CPT II 4009F: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor
blocker (ARB) therapy prescribed
AND
CPT II 3021F: Left ventricular ejection fraction (LVEF) <40% or documentation of
moderately or severely depressed left ventricular systolic function
OR

ACE Inhibitor or ARB Therapy not Prescribed for Medical, Patient, or System
Reasons
(Two CPT II codes [4009F-xP & 3021F] are required on the claim form to submit this
category)
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4009F to report documented
circumstances that appropriately exclude patients from the denominator
• 4009F with 1P: Documentation of medical reason(s) for not prescribing angiotensin
converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
• 4009F with 2P: Documentation of patient reason(s) for not prescribing angiotensin
converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
• 4009F with 3P: Documentation of system reason(s) for not prescribing angiotensin
converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
AND
CPT II 3021F: Left ventricular ejection fraction (LVEF) <40% or documentation of
moderately or severely depressed left ventricular systolic function
OR
If patient is not eligible for this measure because LVEF ≥ 40% or LVEF not
performed or documented, report:
Left Ventricular Ejection Fraction (LVEF) ≥ 40%
(One CPT II code [3022F] is required on the claim form to submit this category)
CPT II 3022F: Left ventricular ejection fraction (LVEF) ≥40% or documentation as normal
or mildly depressed left ventricular systolic function
OR
Left Ventricular Ejection Fraction (LVEF) not Performed or Documented
(One CPT II code [3021F-8P] is required on the claim form to submit this category)

OR

Append a reporting modifier (8P) to CPT Category II code 3021F to report circumstances
when the patient is not eligible for the measure.
• 3021F with 8P: Left ventricular ejection fraction (LVEF) was not performed or
documented

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ACE Inhibitor or ARB Therapy not Prescribed, Reason Not Specified
(Two CPT II codes [4009F-8P & 3021F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4009F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4009F with 8P: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor
blocker (ARB) therapy was not prescribed, reason not otherwise specified
AND
CPT II 3021F: Left ventricular ejection fraction <40% or documentation of moderately or
severely depressed left ventricular systolic dysfunction
DENOMINATOR:
Heart failure patients aged 18 years and older with LVEF < 40% or with moderately or severely
depressed left ventricular systolic function
Denominator Coding:
An ICD-9 diagnosis code for heart failure and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91,
404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
In the absence of contraindications, ACE Inhibitors or ARBs are recommended for all patients with
symptoms of heart failure and reduced left ventricular systolic function, as measured by left
ventricular ejection fraction (LVEF). Both drugs have been shown to decrease mortality and
hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Angiotensin converting enzyme inhibitors are recommended for all patients with current or prior
symptoms of HF and reduced LVEF, unless contraindicated. (Class I Recommendation, Level of
Evidence: A)(ACC/AHA)
Angiotensin II receptor blockers approved for the treatment of HF are recommended in patients
with current or prior symptoms of HF and reduced LVEF who are ACEI-intolerant. (Class I
Recommendation, Level of Evidence: A) (ACC/AHA)

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Angiotensin II receptor blockers are reasonable to use as alternatives to ACEIs as first-line therapy
for patients with mild to moderate HF and reduced LVEF, especially for patients already taking
ARBs for other indications. (Class IIa Recommendation, Level of Evidence: A) (ACC/AHA)

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Measure #6: Oral Antiplatelet Therapy Prescribed for Patients with Coronary Artery
Disease
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease who
were prescribed oral antiplatelet therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with coronary
artery disease seen during the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed oral antiplatelet therapy
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
Numerator Instructions: Oral antiplatelet therapy consists of aspirin, clopidogrel/Plavix,
or combination of aspirin and dipyridamole/Aggrenox
Numerator Coding:
Oral Antiplatelet Therapy Prescribed
CPT II 4011F: Oral antiplatelet therapy prescribed (eg, aspirin, clopidogrel/Plavix, or
combination of aspirin and dipyridamole/Aggrenox)
OR

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OR

Oral Antiplatelet Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to Category II code 4011F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing oral antiplatelet therapy
(eg, aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox)
• 2P: Documentation of patient reason(s) for not prescribing oral antiplatelet therapy (eg,
aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox)
• 3P: Documentation of system reason(s) for not prescribing oral antiplatelet therapy
(eg, aspirin, clopidogrel/Plavix, or combination of aspirin and dipyridamole/Aggrenox)
Oral Antiplatelet Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4011F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Oral antiplatelet therapy (eg, aspirin, clopidogrel/Plavix, or combination of aspirin
and dipyridamole/Aggrenox) was not prescribed, reason not otherwise specified

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of coronary artery disease
Denominator Coding:
An ICD-9 diagnosis code for coronary artery disease and a CPT E/M service code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21,
410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60,
410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92,
411.0, 411.1, 411.81, 411.89, 412, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02, 414.03,
414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Oral antiplatelet therapy, preferably aspirin unless contraindicated, is recommended for all patients
with coronary artery disease. By limiting the ability of clots to form in the arteries, antiplatelet
agents have proven benefits in reducing the risk of non-fatal myocardial infarction, non-fatal stroke
and death.
CLINICAL RECOMMENDATION STATEMENTS:
Chronic Stable Angina: Class I – Aspirin 75-325 mg daily should be used routinely in all patients
with acute and chronic ischemic heart disease with or without manifest symptoms in the absence of
contraindications. Class IIa – Clopidogrel is recommended when aspirin is absolutely
contraindicated. Class III – Dipyridamole. Because even the usual oral doses of dipyridamole can

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enhance exercise-induced myocardial ischemia in patients with stable angina, it should not be
used as an antiplatelet agent. (ACC/AHA/ACP-ASIM)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Class I – Aspirin 75 to 325
mg/dl in the absence of contraindications. Class I – Clopidogrel 75 qd for patients with a
contraindication to ASA. (ACC/AHA)
Acute Myocardial Infarction (AMI): Class I – A dose of aspirin, 160 to 325 mg, should be given on
day one of AMI and continued indefinitely on a daily basis thereafter. Trials suggest long-term use
of aspirin in the postinfarction patient in a dose as low as 75 mg per day can be effective, with the
likelihood that side effects can be reduced. Class IIb – Other antiplatelet agents such as
dipyridamole, ticlopidine or clopidogrel may be substituted if true aspirin allergy is present or if the
patient is unresponsive to aspirin. (ACC/AHA)
Coronary Artery Bypass Graft Surgery: Aspirin is the drug of choice for prophylaxis against early
saphenous graft thrombotic closure and should be considered a standard of care for the first
postoperative year. In general, patients are continued on aspirin indefinitely, given its benefit in the
secondary prevention of AMI. Ticlopidine is efficacious but offers no advantage over aspirin except
as an alternative in the truly aspirin-allergic patient. Clopidogrel offers the potential of fewer side
effects compared with ticlopidine as an alternative to aspirin for platelet inhibition. Indobufen
appears to be as effective as aspirin for saphenous graft patency over the first postoperative year
but with fewer gastrointestinal side effects. Current evidence suggests that dipyridamole adds
nothing to the aspirin effect for saphenous graft patency. (ACC/AHA)

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Measure #7: Beta-blocker Therapy for Coronary Artery Disease Patients with Prior
Myocardial Infarction (MI)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease and
prior myocardial infarction (MI) who were prescribed beta-blocker therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with prior
myocardial infarction (MI) seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed beta-blocker therapy
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
Numerator Coding:
Beta-blocker Therapy Prescribed
CPT II 4006F: Beta-blocker therapy prescribed
OR

OR

Beta-blocker Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4006F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing beta-blocker therapy
• 2P: Documentation of patient reason(s) for not prescribing beta-blocker therapy
• 3P: Documentation of system reason(s) for not prescribing beta-blocker therapy

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Beta-blocker Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4006F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Beta-blocker therapy was not prescribed, reason not otherwise specified
DENOMINATOR:
Patients aged 18 years and older with a diagnosis of coronary artery disease who also have prior
myocardial infarction (MI) at any time
Denominator Coding:
An ICD-9 diagnosis code for coronary artery disease* and myocardial infarction and a CPT
E/M service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 414.00,
414.01, 414.02, 414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82,
410.00*, 410.01*, 410.02*, 410.10*, 410.11*, 410.12*, 410.20*, 410.21*, 410.22*, 410.30*,
410.31*, 410.32*, 410.40*, 410.41*, 410.42*, 410.50*, 410.51*, 410.52*, 410.60*, 410.61*,
410.62*, 410.70, 410.71*, 410.72*, 410.80*, 410.81*, 410.82*, 410.90*, 410.91*, 410.92*,
412*
AND
Patients who had a prior MI at any time
ICD-9 diagnosis codes: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20, 410.21,
410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52, 410.60,
410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91, 410.92,
412
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99238, 99239, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
*Denominator inclusion for this measure requires the presence of a prior MI
diagnosis AND at least one E/M code during the measurement period. Diagnosis
codes for Coronary Artery Disease (which include MI diagnosis codes) may also
accompany the MI diagnosis code, but are not required for inclusion in the measure.
RATIONALE:
In the absence of contraindications, beta-blocker therapy has been shown to reduce the risk of a
recurrent MI and decrease mortality for those patients with a prior MI.
CLINICAL RECOMMENDATION STATEMENTS:
Chronic Stable Angina: Class I – Beta-blockers as initial therapy in the absence of
contraindications in patients with prior MI. Class I – Beta-blockers as initial therapy in the absence
of contraindications in patients without prior MI. (ACC/AHA/ACP-ASIM)
Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction: Class I – Drugs required in
the hospital to control ischemia should be continued after hospital discharge in patients who do not

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undergo coronary revascularization, patients with unsuccessful revascularization, or patients with
recurrent symptoms after revascularization. Upward or downward titration of the doses may be
required. Class I – Beta-blockers in the absence of contraindications. (ACC/AHA)
Acute Myocardial Infarction: Class I – All but low-risk patients without a clear contraindication to ßadrenoceptor blocker therapy. Treatment should begin within a few days of the event (if not
initiated acutely) and continue indefinitely. Class IIa – Low-risk patients without a clear
contraindication to ß-adrenoceptor blocker therapy. Survivors of non-ST-elevation MI. Class IIb –
Patients with moderate or severe LV failure or other relative contraindications to ß-adrenoceptor
blocker therapy, provided they can be monitored closely. (ACC/AHA)
Although no study has determined if long-term ß-adrenoceptor blocker therapy should be
administered to survivors of MI who subsequently have successfully undergone revascularization,
there is no reason to believe that these agents act differently in coronary patients who have
undergone revascularization. (ACC/AHA)

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Measure #8: Heart Failure: Beta-blocker Therapy for Left Ventricular Systolic Dysfunction
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of heart failure who also have left
ventricular systolic dysfunction (LVSD) and who were prescribed beta blocker therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all heart failure patients
seen during the reporting period. This measure is intended to reflect the quality of services
provided for patients with heart failure and decreased left ventricular systolic function. The left
ventricular systolic dysfunction may be determined by quantitative or qualitative assessment, which
may be current or historical. Examples of a quantitative or qualitative assessment may include an
echocardiogram: 1) that provides a numerical value of left ventricular systolic dysfunction or 2) that
uses descriptive terms such as moderately or severely depressed left ventricular dysfunction. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. G-codes are used to
report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who were prescribed beta-blocker therapy
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
Numerator Coding:
Beta-blocker Therapy Prescribed
G8450: Beta-blocker therapy prescribed for patients with left ventricular ejection fraction
(LVEF) <40% or documentation as moderately or severely depressed left ventricular
systolic function
OR

Beta-blocker Therapy not Prescribed for Documented Reasons
G8451: \Clinician documented patient with left ventricular ejection fraction (LVEF) <40%
or documentation as moderately or severely depressed left ventricular systolic function
was not eligible candidate for beta-blocker therapy
OR

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If patient is not eligible for this measure because LVEF ≥ 40% or LVEF not
performed or documented, report:
Left Ventricular Ejection Fraction (LVEF) ≥ 40%
G8395: Left ventricular ejection fraction (LVEF) ≥ 40% or documentation as normal or
mildly depressed left ventricular systolic function
OR
Left Ventricular Ejection Fraction (LVEF) not Performed or Documented
G8396: Left ventricular ejection fraction (LVEF) not performed or documented
OR

Beta-blocker Therapy not Prescribed, Reason not Specified
G8452: Beta-blocker therapy not prescribed for patients with left ventricular ejection
fraction (LVEF) <40% or documentation as moderately or severely depressed left
ventricular systolic function

DENOMINATOR:
Patients aged 18 years and older with a diagnosis of heart failure with left ventricular ejection
fraction (LVEF) < 40% or with moderately or severely depressed left ventricular systolic function
Denominator Coding:
An ICD-9 diagnosis code for heart failure and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 402.01, 402.11, 402.91, 404.01, 404.03, 404.11, 404.13, 404.91,
404.93, 428.0, 428.1, 428.20, 428.21, 428.22, 428.23, 428.30, 428.31, 428.32, 428.33,
428.40, 428.41, 428.42, 428.43, 428.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Beta-blockers are recommended for all patients with symptoms of heart failure and left ventricular
systolic dysfunction, unless contraindicated. Treatment with beta-blockers has been shown to
provide multiple benefits to the patient, including reducing the symptoms of heart failure, improving
the clinical status of patients, and decreasing the risk of mortality and hospitalizations.
CLINICAL RECOMMENDATION STATEMENTS:
Beta-blockers (using 1 of the 3 proven to reduce mortality, i.e., bisoprolol, carvedilol, and sustained
release metoprolol succinate) are recommended for all stable patients with current or prior
symptoms of HF and reduced LVEF, unless contraindicated. (Class I Recommendation, Level of
Evidence: A) (ACC/AHA)

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Measure #9: Antidepressant Medication During Acute Phase for Patients with New
Episode of Major Depression
DESCRIPTION:
Percentage of patients aged 18 years and older diagnosed with new episode of major depressive
disorder (MDD) and documented as treated with antidepressant medication during the entire 84day (12 week) acute treatment phase
INSTRUCTIONS:
This measure is to be reported for each occurrence of MDD during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. G-codes are used to report the
numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients with an 84-day (12 week) acute treatment of antidepressant medication
Numerator Instructions: Report G8126: 1) For all patients with a diagnosis of Major
Depression, New Episode who were prescribed a full 12-week course of antidepressant
medication OR 2) At the completion of a 12-week course of antidepressant medication.
Definition: A "new episode" is defined as a patient with major depression who has not
been seen or treated for major depression by any practitioner in the prior 4 months. A new
episode can either be a recurrence for a patient with prior major depression or a patient
with a new onset of major depression.

OR

Numerator Coding:
Acute Treatment with Antidepressant Medication
G8126: Patient with new episode of MDD documented as being treated with
antidepressant medication during the entire 12 week acute treatment phase
Acute Treatment with Antidepressant Medication not Completed for Documented
Reasons
G8128: Clinician documented that patient with a new episode of MDD was not an eligible
candidate for antidepressant medication treatment or patient did not have a new episode
of MDD

OR

22

12/31/2007

Acute Treatment with Antidepressant Medication not Completed
G8127: Patient with new episode of MDD not documented as being treated with
antidepressant medication during the entire 12 week acute treatment phase
DENOMINATOR:
Patients 18 years and older diagnosed with a New Episode of MDD (major depression) and treated
with antidepressant medication
Denominator Coding:
An ICD-9 diagnosis code for MDD and a CPT code are required to identify patients for
denominator inclusion.
ICD-9 diagnosis codes: 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32,
296.33, 296.34, 298.0, 300.4, 309.1, 311
AND
CPT E/M service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809,
90862, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241, 99242,
99243, 99244, 99245, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
The consequences of untreated, or inadequately treated, depression are significant; therefore,
adherence to antidepressant medication is very important. Clinical guidelines for depression stress
the importance of effective clinical management in increasing patients’ medication compliance,
monitoring treatment effectiveness, and identifying and managing side effects. If pharmacological
treatment is initiated, appropriate dosing and continuation of therapy through the acute and
continuation phases decreases recurrence of depression. Thus, evaluation of length of treatment
serves as an important indicator of success in promoting patient compliance with the establishment
and maintenance of an effective medication regimen.
CLINICAL RECOMMENDATION STATEMENTS:
Successful treatment of patients with major depressive disorder is promoted by a thorough
assessment of the patient and close adherence to treatment plans. Treatment consists of an acute
phase, during which remission is induced; a continuation phase, during which remission is
preserved; and a maintenance phase, during which the susceptible patient is protected against the
recurrence of a subsequent major depressive episode. Patients who have been treated with
antidepressant medications in the acute phase should be maintained on these agents to prevent
relapse. American Psychiatric Association (APA) Practice Guideline for the Treatment of Patients
with Major Depressive Disorder, 2000
Antidepressants should be continued for at least 6 months after remission of an episode of
depression, because this greatly reduces the risk of relapse. (A: At least one randomized controlled
trial as part of a body of literature of overall good quality and consistency addressing the specific
recommendation (evidence level-I) without extrapolation) National Institute for Clinical Excellence
(UK), Management of Depression in Primary and Secondary Care, 2004
In recent years, major depression has come to be considered a chronic and/or recurrent, rather
than an acute illness. This reevaluation of the disorder has inherent treatment implications because
patients with major depression tend to exhibit episodic recurrence and/or chronic residual

23

12/31/2007

symptoms. Considering this, the management of depression can be divided into the acute phase
(suppression of symptoms to achieve clinical remission), lasting 8 to 12 weeks, and the
maintenance phase (prevention of relapse/recurrence), lasting 6 months or longer. Clinical
management is an important component of pharmacotherapy; and includes a brief session of
psychoeducation and supportive strategies. During the maintenance phase after remission of acute
symptoms, all patients should continue the antidepressant dose that induced remission for at least
6 months. The relapse rate is 35% to 60% if antidepressants are discontinued in the first 6 months,
compared with 10% to 25% in patients who continue medications. The risk of relapse is particularly
high if drug discontinuation occurs in the first few months of response/remission. Canadian
Psychiatric Association, 2001

24

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Measure #10: Stroke and Stroke Rehabilitation: Computed Tomography (CT) or Magnetic
Resonance Imaging (MRI) Reports
DESCRIPTION:
Percentage of final reports for CT or MRI studies of the brain performed within 24 hours of arrival to
the hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or
transient ischemic attack (TIA) or intracranial hemorrhage or at least one documented symptom
consistent with ischemic stroke or TIA or intracranial hemorrhage that includes documentation of
the presence or absence of each of the following: hemorrhage and mass lesion and acute
infarction
INSTRUCTIONS:
This measure is to be reported each time a CT or MRI is performed in a hospital or outpatient
setting during the reporting period for patients with a diagnosis or symptom of ischemic stroke, TIA,
or intracranial hemorrhage. It is anticipated that clinicians who provide the physician component of
diagnostic imaging studies for patients with stroke, TIA, or intracranial hemorrhage in the hospital
or outpatient setting will submit this measure. NOTE: Use of symptom codes is limited to those
specified in the denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis and symptom codes, CPT procedure codes, and patient demographics (age,
gender, etc.) are used to identify patients who are included in the measure’s denominator. CPT
Category II codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis or symptom codes, CPT procedure
codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified.
There are no allowable performance exclusions for this measure.
NUMERATOR:
Final reports of the initial CT or MRI that include documentation of the presence or absence of
each of the following: hemorrhage and mass lesion and acute infarction
Definition: Equivalent terms or synonyms for hemorrhage, mass lesion, or infarction, if
documented in the CT or MRI report, would meet the measure
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction Documented
(Two CPT II codes [3110F & 3111F] are required on the claim form to submit this
category)

25

12/31/2007

CPT II 3110F: Presence or absence of hemorrhage and mass lesion and acute infarction
documented in final CT or MRI report
AND
CPT II 3111F: CT or MRI of the brain performed within 24 hours of arrival to the hospital
OR

OR

If patient is not eligible for this measure because CT or MRI of the brain was
performed greater than 24 hours after arrival to the hospital, report:
(One CPT II code [3112F] is required on the claim form to submit this category)
CPT II 3112F: CT or MRI of the brain performed greater than 24 hours after arrival to the
hospital
Presence/Absence of Hemorrhage, Mass Lesion, and Acute Infarction not
Documented, Reason not Specified
(Two CPT II codes [3110F-8P & 3111F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3110F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3110F with 8P: Presence or absence of hemorrhage and mass lesion and acute
infarction was not documented in final CT or MRI report, reason not otherwise
specified
AND
CPT II 3111F: CT or MRI of the brain within 24 hours of arrival to the hospital

DENOMINATOR:
All final reports for CT or MRI studies of the brain performed within 24 hours of arrival to the
hospital for patients aged 18 years and older with either a diagnosis of ischemic stroke or TIA or
intracranial hemorrhage OR at least one documented symptom consistent with ischemic stroke or
TIA or intracranial hemorrhage
Denominator Coding:
For purposes of this measure, the listed symptoms will be considered “documented
symptoms consistent” with ischemic stroke or TIA or intracranial hemorrhage. Each of the
listed symptoms corresponds to a specific ICD-9 code in the code table below. NOTE:
Use of symptom codes is limited to the following:
•
•
•
•
•
•

Transient visual loss (368.12)
Diplopia (double vision) (368.2)
Vertigo of central origin (386.2)
Transient global amnesia (437.7)
Transient alteration of awareness (780.02)
Lack of coordination (781.3)

26

•
•
•
•
•

Transient paralysis of limb (781.4)
Facial weakness (781.94)
Disturbance of skin sensation (782.0)
Aphasia (784.3)
Slurred speech (784.5)

12/31/2007

A CPT procedure code for patients undergoing CT or MRI of the brain and either an ICD-9
diagnosis code to identify patients with a diagnosis of ischemic stroke or TIA or intracranial
hemorrhage OR a specified symptom code are required for denominator inclusion.
ICD-9 diagnosis and symptom codes: 368.12, 368.2, 386.2, 431, 433.01, 433.11,
433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, 435.0, 435.1, 435.2, 435.3,
435.8, 435.9, 437.7, 780.02, 781.3, 781.4, 781.94, 782.0, 784.3, 784.5
AND
CPT procedure codes: 0042T, 70450, 70460, 70470, 70551, 70552, 70553
RATIONALE:
The CT and MRI findings are critical to initiating care for the patient with stroke. All CT and MRI
reports should address the presence or absence of these three important findings. This
documentation is particularly vital in the report of the first imaging study performed after arrival at
the hospital, on which initial treatment decisions will be based.
CLINICAL RECOMMENDATION STATEMENTS:
Brain imaging is required to guide acute intervention. (Grade A) There is a uniform agreement that
CT accurately identifies most cases of intracranial hemorrhage and helps discriminate nonvascular
causes of neurological symptoms, e.g., brain tumor. (Grade B) With the advent of rtPA treatment,
interest has grown in using CT to identify subtle, early signs of ischemic brain injury (early infarct
signs) or arterial occlusion that might affect decisions about treatment. The presence of these signs
is associated with poor outcomes. (Adams, ASA, 2003) (Class A)
A technically adequate head CT scan is required prior to administration of thrombolytic therapy to
exclude brain hemorrhage and nonischemic diagnoses. The baseline CT scan is also sensitive for
detection of early signs of cerebral infarction. Subtle or limited signs of early infarction on the CT
scan are common even within the first 3 h of stroke evolution.
Preliminary data suggest that specific MRI profiles may identify patients who are particularly likely
to benefit from thrombolytic therapy. New MRI techniques including perfusion-weighted and
diffusion-weighted may detect ischemic injury in the first hour and may reveal the extent of
reversible and irreversible injury. In addition, MRI appears to be highly sensitive for identification of
acute brain hemorrhage. (Albers, ACCP, 2004)

27

12/31/2007

Measure #11: Stroke and Stroke Rehabilitation: Carotid Imaging Reports
DESCRIPTION:
Percentage of final reports for carotid imaging studies (neck MR angiography [MRA], neck CT
angiography [CTA], neck duplex ultrasound, carotid angiogram) performed for patients aged 18
years and older with the diagnosis of ischemic stroke or transient ischemic attack (TIA) that include
direct or indirect reference to measurements of distal internal carotid diameter as the denominator
for stenosis measurement
INSTRUCTIONS:
This measure is to be reported each time a carotid imaging study is performed during the reporting
period for patients with a diagnosis of ischemic stroke or TIA. It is anticipated that clinicians who
provide the physician component of diagnostic imaging studies for patients with stroke or TIA in the
hospital or outpatient setting will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, and
the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Final carotid imaging study reports that include direct or indirect reference to measurements of
distal internal carotid diameter as the denominator for stenosis measurement
Definition: “Direct or indirect reference to measurements of distal internal carotid diameter
as the denominator for stenosis measurement” includes direct angiographic stenosis
calculation based on the distal lumen as the denominator for stenosis measurement OR an
equivalent validated method referenced to the above method (e.g., for duplex ultrasound
studies, velocity parameters that correlate the residual internal carotid lumen with methods
based on the distal internal carotid lumen)
Numerator Coding:
Reference to Measurements of Distal Internal Carotid Diameter as the Denominator
for Stenosis Measurement Documented
CPT II 3100F: Carotid image study report includes direct or indirect reference to
measurements of distal internal carotid diameter as the denominator for stenosis
measurement
OR

28

12/31/2007

Measurements of Distal Internal Carotid Diameter not Referenced for Medical
Reasons
Append a modifier (1P) to CPT Category II code 3100F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not including direct or indirect reference to
measurements of distal internal carotid diameter
OR

Measurements of Distal Internal Carotid Diameter not Referenced, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 3100F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Carotid image study report did not include direct or indirect reference to
measurements of distal internal carotid diameter as the denominator for stenosis
measurement, reason not otherwise specified

DENOMINATOR:
All final reports for carotid imaging studies (neck MR angiography [MRA], neck CT angiography
[CTA], neck duplex ultrasound, carotid angiogram) performed for patients aged 18 years and older
with a diagnosis of ischemic stroke or TIA
Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke or TIA and a CPT procedure code for patients
undergoing carotid imaging are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,
434.91, 435.0, 435.1, 435.2, 435.3, 435.8, 435.9
AND
CPT procedure codes: 70498, 70547, 70548, 70549, 75660, 75662, 75665, 75671,
75676, 75680, 93880, 93882
RATIONALE:
Since the clinical decision-making is based on randomized trial evidence and degree of stenosis is
an important element of the decision for carotid intervention, characterization of the degree of
stenosis needs to be standardized. Requiring that stenosis calculation be based on a denominator
of distal internal carotid diameter or, in the case of duplex ultrasound, velocity measurements that
have been correlated to angiographic stenosis calculation based on distal internal carotid diameter,
makes the measure applicable to both imaging and duplex studies.
CLINICAL RECOMMENDATION STATEMENTS:
For patients with symptomatic atherosclerotic carotid stenosis > 70%, as defined using the
NASCET criteria, the value of carotid endarterectomy (CEA) has been clearly established from the
results of 3 major prospective randomized trials: the NASCET, the European Carotid Surgery Trial
(ECST), and the Veterans Affairs Cooperative Study Program. Among symptomatic patients with
TIAs or minor strokes and high-grade carotid stenosis, each trial showed impressive relative and
absolute risk reductions for those randomized to surgery. For patients with carotid stenosis < 50%,
these trials showed that there was no significant benefit of surgery. (Sacco, ASA, 2006)

29

12/31/2007

It is important to consider that the degree of carotid stenosis in ECST was measured differently
than that in NASCET. The degree of carotid stenosis is significantly higher if calculated by the
NASCET rather than the ECST method. In summary, it appears that patients with a recent TIA or
nondisabling stroke with ipsilateral carotid stenosis benefit from surgery if the stenosis is > 50% as
measured by the NASCET method; however, this benefit appears to be less pronounced in
women. Recently symptomatic patients with > 70% stenosis as measured by the NASCET method
can expect a far greater benefit from carotid endarterectomy. (Albers, AHA, 1999)

30

12/31/2007

Measure #12: Primary Open Angle Glaucoma: Optic Nerve Evaluation
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
(POAG) who have an optic nerve head evaluation during one or more office visits within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with primary open-angle glaucoma (in either one or both eyes) will submit this measure. The
system reason exclusion may be used if a clinician is asked to report on this measure but is not the
clinician providing the primary management for primary open-angle glaucoma.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT codes, and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The modifiers
allowed for this measure are: 1P- medical reasons, 3P-system reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who have an optic nerve head evaluation during one or more office visits within 12 months
Numerator Coding:
Optic Nerve Head Evaluation Performed
CPT II 2027F: Optic nerve head evaluation performed
OR

OR

Optic Nerve Head Evaluation not Performed for Medical or System Reasons
Append a modifier (1P or 3P) to CPT Category II code 2027F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing an optic nerve head
evaluation
• 3P: Documentation of system reason(s) for not performing an optic nerve head
evaluation
Optic Nerve Head Evaluation not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2027F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Optic nerve head evaluation was not performed, reason not otherwise specified

31

12/31/2007

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of primary open-angle glaucoma
Denominator Coding:
An ICD-9 diagnosis code for primary open-angle glaucoma and a CPT code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 365.01, 365.10, 365.11, 365.12, 365.15
AND
CPT codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
Changes in the optic nerve are one of two characteristics which currently define progression and
thus worsening of glaucoma disease status (the other characteristic is visual field). There is a
significant gap in documentation patterns of the optic nerve for both initial and follow-up care
(Fremont, 2003), even among specialists (Lee, 2006). Examination of the optic nerve head and
retinal nerve fiber layer provides valuable structural information about glaucomatous optic nerve
damage. Visible structural alterations of the optic nerve head or retinal nerve fiber layer and
development of peripapillary choroidal atrophy frequently occur before visual field defects can be
detected.{ ADDIN EN.CITE
Jonas20044749474917Jonas, J. B.Martus,
P.Horn, F. K.Junemann, A.Korth,
M.Budde, W. M.Department
of Ophthalmology and Eye Hospital, University Erlangen-Nurnberg, Erlangen, Germany.
jost.jonas@augen.ma.uni-heidelberg.dePredictive factors of the optic
nerve head for development or progression of glaucomatous visual field lossInvest Ophthalmol Vis Sci26138458Chronic
DiseaseDisease
ProgressionFemaleGlaucoma, OpenAngle/*diagnosisHumansIntraocular
PressureMaleMiddle
AgedOcular Hypertension/diagnosisOptic
Disk/*pathologyOptic Nerve
Diseases/*diagnosisProspective StudiesResearch
Support, Non-U.S. Gov'tRisk FactorsVision
Disorders/*diagnosis*Visual
Fields2004Aug15277484http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&do
pt=Citation&list_uids=15277484Uchida19981952
195217Uchida, H.Ugurlu,

32

12/31/2007

S.Caprioli, J.Department of
Ophthalmology and Visual Science, Yale University School of Medicine, New Haven, Connecticut,
USA.Increasing peripapillary atrophy is associated with progressive
glaucomaOphthalmologyOphthalmology154151058Adult<
keyword>AgedAged, 80 and overCohort
StudiesDisease
ProgressionFemaleFollow-Up
StudiesGlaucoma, Open-Angle/complications/
physiopathologyHumanIncidenceIntraocular PressureMaleMiddle
AgedOptic Atrophy/complications/
physiopathologyOptic Disk/physiopathologyOptic
Nerve/physiopathologyPerimetryRetrospective
StudiesSupport, Non-U.S. Gov'tSupport, U.S.
Gov't, P.H.S.Visual AcuityVisual
Fields1998Aug9709771Sommer19913027302717Sommer, A.Katz,
J.Quigley, H. A.Miller, N. R.Robin, A.
L.Richter, R. C.Witt, K.
A.Dana Center for Preventive Ophthalmology,
Wilmer Eye Institute, Baltimore, Md.Clinically detectable nerve fiber
atrophy precedes the onset of glaucomatous field lossArch
OphthalmolArch Ophthalmol77831091Adult
AgedFemaleFollow-Up
StudiesFundus OculiGlaucoma/
pathology/physiopathologyHumanLongitudinal
StudiesMaleMiddle
AgedNerve Fibers/pathologyOptic Atrophy/
pathologyPerimetryPhotographyProspective StudiesSupport, U.S. Gov't,
P.H.S.Visual
Fields1991Jan1987954Zeyen19934460446017Zeyen, T. G.Caprioli,
J.Department of Ophthalmology and Visual
Science, Yale University School of Medicine, New Haven, Conn 06510.Progression of disc and field damage in early glaucomaArch OphthalmolArch Ophthalmol6251111Follow-Up
StudiesFundus OculiGlaucoma, OpenAngle/pathology/*physiopathologyHumanIncidenceLongitudinal StudiesOptic
Disk/*pathologyOptic Nerve
Diseases/pathologyPerimetry/methodsRetrospective
StudiesSupport, Non-U.S. Gov'tSupport, U.S.
Gov't, P.H.S.Vision
Disorders/*physiopathology*Visual
Fields1993Jan8424726http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&do
pt=Citation&list_uids=8424726Sommer1979445
8445817Sommer, A.Pollack,
I.Maumenee, A. E.Optic disc
parameters and onset of glaucomatous field loss. I. Methods and progressive changes in disc
morphologyArch OphthalmolArch Ophthalmol14448978Glaucoma/*patholo
gy/physiopathologyHumanMethodsOptic
Disk/*pathology/physiopathologyPhotogrammetryVis
ual Fields1979Aug464866http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&do
pt=Citation&list_uids=464866Pederson198040
42404217Pederson, J. E.Anderson, D.
R.The mode of progressive disc cupping in ocular
hypertension and glaucomaArch OphthalmolArch Ophthalmol4905983AdultAgedGlaucoma/pathology/
physiopathologyHumanIntraocular
PressureMiddle AgedOptic Disk/pathology/
physiopathologyPerimetryPhotographyVisual Fields1980Mar7362506Hart19794
459445917Hart, W. M.,
Jr.Yablonski, M.Kass, M. A.Becker,

34

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B.Multivariate analysis of the risk of glaucomatous
visual field lossArch OphthalmolArch Ophthalmol14558978Glaucoma/*physiop
athologyHumanModels,
BiologicalRegression AnalysisRetrospective
StudiesRiskSupport, U.S. Gov't,
P.H.S.*Visual
Fields1979Aug464868http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&do
pt=Citation&list_uids=464868Yablonski198044
61446117Yablonski, M. E.Zimmerman, T.
J.Kass, M. A.Becker,
B.Prognostic significance of optic disk cupping in
ocular hypertensive patientsAm J OphthalmolAm J Ophthalmol58592894Aged<
keyword>FemaleFollow-Up
StudiesGlaucoma/diagnosis/*physiopathologyHuman
*Intraocular
PressureMaleMiddle
AgedOptic
Disk/*physiopathologyPhotographyPrognosisSupport, U.S. Gov't, P.H.S.Visual
Fields1980Apr7369323http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&do
pt=Citation&list_uids=7369323Odberg19853585
358517Odberg, T.Riise,
D.Early diagnosis of glaucoma. The value of
successive stereophotography of the optic discActa Ophthalmol
(Copenh)25763633Adult<
keyword>AgedFemaleFollow-Up
StudiesGlaucoma/
diagnosis/pathologyHumanMaleMiddle AgedOptic Disk/
pathologyPhotographyProspective
StudiesVisual
Fields1985Jun4036552} Careful study of the optic disc neural rim for small

35

12/31/2007

hemorrhages is important, since these hemorrhages can precede visual field loss and further optic
nerve damage.
CLINICAL RECOMMENDATION STATEMENTS:
The physical exam focuses on nine elements: visual acuity, pupils, slit-lamp biomicroscopy of the
anterior segment, measurement of intraocular pressure (IOP), determination of central corneal
thickness, gonioscopy, evaluation of optic nerve head and retinal nerve fiber layer, documentation
of optic nerve head appearance, evaluation of fundus (through dilated pupil), and evaluation of the
visual field (Level A: II Recommendation for optic nerve head evaluation) (AAO, 2005).

36

12/31/2007

Measure #14: Age-Related Macular Degeneration: Dilated Macular Examination
DESCRIPTION:
Percentage of patients aged 50 years and older with a diagnosis of age-related macular
degeneration who had a dilated macular examination performed which included documentation of
the presence or absence of macular thickening or hemorrhage AND the level of macular
degeneration severity during one or more office visits within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with age-related macular degeneration (in either one or both eyes) will submit this measure. The
system reason exclusion may be used if a clinician is asked to report on this measure but is not the
clinician providing the primary management for age-related macular degeneration.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT codes, and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The modifiers
allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P-system reasons, 8Preasons not otherwise specified.
NUMERATOR:
Patients who had a dilated macular examination performed which included documentation of the
presence or absence of macular thickening or hemorrhage AND the level of macular degeneration
severity during one or more office visits within 12 months
Numerator Coding:
Dilated Macular Examination Performed
CPT II 2019F: Dilated macular exam performed, including documentation of the presence
or absence of macular thickening or hemorrhage AND the level of macular degeneration
severity
OR

Dilated Macular Examination not Performed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 2019F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing a dilated macular
examination
• 2P: Documentation of patient reason(s) for not performing a dilated macular
examination
• 3P: Documentation of system reason(s) for not performing a dilated macular
examination

37

12/31/2007

OR

Dilated Macular Examination not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2019F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Dilated macular exam was not performed, reason not otherwise specified

DENOMINATOR:
All patients aged 50 years and older with a diagnosis of age-related macular degeneration
Denominator Coding:
An ICD-9 diagnosis code for age-related macular degeneration and a CPT code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 362.50, 362.51, 362.52
AND
CPT codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
A documented complete macular examination is a necessary prerequisite to determine the
presence and severity of AMD, so that a decision can be made as to the benefits of prescribing
antioxidant vitamins. Further, periodic assessment is necessary to determine whether there is
progression of the disease and to plan the on-going treatment of the disease, since several
therapies exist that reduce vision loss once the advanced “wet” form of AMD occurs. While no data
exist on the frequency or absence of regular examinations of the macula for patients with AMD,
parallel data for key structural assessments for glaucoma and cataract and diabetic retinopathy
suggest that significant gaps are likely.
CLINICAL RECOMMENDATION STATEMENTS:
According to the American Academy of Ophthalmology, a stereo biomicroscopic examination of the
macula should be completed. Binocular slit-lamp biomicroscopy of the ocular fundus is often
necessary to detect subtle clinical clues of CNV. These include small areas of hemorrhage, hard
exudates, subretinal fluid, or pigment epithelial elevation (Level A: III Recommendation) (AAO,
2005).

38

12/31/2007

Measure #18: Diabetic Retinopathy: Documentation of Presence or Absence of Macular
Edema and Level of Severity of Retinopathy
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a
dilated macular or fundus exam performed which included documentation of the level of severity of
retinopathy and the presence or absence of macular edema during one or more office visits within
12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide the primary management of patients
with diabetic retinopathy (in either one or both eyes) will submit this measure. The system reason
exclusion may be used if a clinician is asked to report on this measure but is not the clinician
providing the primary management for diabetic retinopathy.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT codes, and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The modifiers
allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P-system reasons, 8Preasons not otherwise specified.
NUMERATOR:
Patients who had a dilated macular or fundus exam performed which included documentation of
the level of severity of retinopathy AND the presence or absence of macular edema during one or
more office visits within 12 months
Definition: Medical record must include: Documentation of the level of severity of
retinopathy (e.g., background diabetic retinopathy, proliferative diabetic retinopathy,
nonproliferative diabetic retinopathy) AND documentation of whether macular edema was
present or absent

OR

Numerator Coding:
Macular or Fundus Exam Performed
CPT II 2021F: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy

39

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OR

Macular or Fundus Exam not Performed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 2021F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing a dilated macular or fundus
examination
• 2P: Documentation of patient reason(s) for not performing a dilated macular or fundus
examination
• 3P: Documentation of system reason(s) for not performing a dilated macular or fundus
examination
Macular or Fundus Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2021F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Dilated macular or fundus exam was not performed reason not otherwise specified

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetic retinopathy
Denominator Coding:
An ICD-9 diagnosis code for diabetic retinopathy and a CPT code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 362.01, 362.02, 362.03, 362.04, 362.05, 362.06
AND
CPT codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
Several level 1 RCT studies demonstrate the ability of timely treatment to reduce the rate and
severity of vision loss from diabetes (Diabetic Retinopathy Study - DRS, Early Treatment Diabetic
Retinopathy Study - ETDRS). Necessary examination prerequisites to applying the study results
are that the presence and severity of both peripheral diabetic retinopathy and macular edema be
accurately documented. In the RAND chronic disease quality project, while administrative data
indicated that roughly half of the patients had an eye exam in the recommended time period, chart
review data indicated that only 19% had documented evidence of a dilated examination. (McGlynn,
2003). Thus, ensuring timely treatment that could prevent 95% of the blindness due to diabetes
requires the performance and documentation of key examination parameters. The documented
level of severity of retinopathy and the documented presence or absence of macular edema assists
with the on-going plan of care for the patient with diabetic retinopathy.
CLINICAL RECOMMENDATION STATEMENTS:
Since treatment is effective in reducing the risk of visual loss, detailed examination is indicated to
assess for the following features that often lead to visual impairment: presence of macular edema,
optic nerve neovascularization and/or neovascularization elsewhere, signs of severe NPDR and
vitreous or preretinal hemorrhage. (Level A:III Recommendation) (AAO, 2003)

40

12/31/2007

Measure #19: Diabetic Retinopathy: Communication with the Physician Managing
Ongoing Diabetes Care
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a
dilated macular or fundus exam performed with documented communication to the physician who
manages the ongoing care of the patient with diabetes mellitus regarding the findings of the
macular or fundus exam at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with diabetic
retinopathy seen during the reporting period. It is anticipated that clinicians who provide the primary
management of patients with diabetic retinopathy (in either one or both eyes) will submit this
measure. The system reason exclusion may be used if a clinician is asked to report on this
measure but is not the clinician providing the primary management for diabetic retinopathy.
This measure is reported using CPT Category II codes and/or G-codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II and/or G-codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT codes, and the
appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the modifier
AND G-code. The modifiers allowed for this measure are: 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients with documentation, at least once within 12 months, of the findings of the dilated macular
or fundus exam via communication to the physician who manages the patient’s diabetic care
Definition: Communication may include: Documentation in the medical record indicating
that the results of the dilated macular or fundus exam were communicated (e.g., verbally,
by letter) with the clinician managing the patient’s diabetic care OR a copy of a letter in the
medical record to the clinician managing the patient’s diabetic care outlining the findings of
the dilated macular or fundus exam.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

41

12/31/2007

Numerator Coding:
Dilated Macular or Fundus Exam Findings Communicated
(One CPT II code & one G-code [5010F & G8397] are required on the claim form to submit
this category)
CPT II 5010F: Findings of dilated macular or fundus exam communicated to the physician
managing the diabetes care
AND
G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
OR

Dilated Macular or Fundus Exam Findings not Communicated for Patient or System
Reasons
(One CPT II code & one G-code [5010F-xP & G8397] are required on the claim form to
submit this category)
Append a modifier (2P or 3P) to CPT Category II code 5010F to report documented
circumstances that appropriately exclude patients from the denominator.
• 5010F with 2P: Documentation of patient reason(s) for not communicating the findings
of the dilated macular or fundus exam to the physician who manages the ongoing care
of the patient with diabetes
• 5010F with 3P: Documentation of system reason(s) for not communicating the
findings of the dilated macular or fundus exam to the physician who manages the
ongoing care of the patient with diabetes
AND
G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
OR
If patient is not eligible for this measure because patient did not have dilated
macular or fundus exam performed, report:
(One G-code [G8398] is required on the claim form to submit this category)

OR

G8398: Dilated macular or fundus exam not performed
Dilated Macular or Fundus Exam Findings not Communicated, Reason not Specified
(One CPT II code & one G-code [5010F-8P & G8397] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 5010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 5010F with 8P: Findings of dilated macular or fundus exam was not communicated to
the physician managing the diabetes care, reason not otherwise specified
AND

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12/31/2007

G8397: Dilated macular or fundus exam performed, including documentation of the
presence or absence of macular edema AND level of severity of retinopathy
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated
macular or fundus exam performed
Denominator Coding:
An ICD-9 diagnosis code for diabetic retinopathy and a CPT code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 362.01, 362.02, 362.03, 362.04, 362.05, 362.06
AND
CPT codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
The physician that manages the ongoing care of the patient with diabetes should be aware of the
patient’s dilated eye examination and severity of retinopathy to manage the on-going diabetes
care. Such communication is important in assisting the physician to better manage the diabetes.
Several studies have shown that better management of diabetes is directly related to lower rates of
development of diabetic eye disease. (Diabetes Control and Complications Trial - DCCT, UK
Prospective Diabetes Study - UKPDS)
CLINICAL RECOMMENDATION STATEMENTS:
While it is clearly the responsibility of the ophthalmologist to manage eye disease, it is also the
ophthalmologist’s responsibility to ensure that patients with diabetes are referred for appropriate
management of their systemic condition. It is the realm of the patient’s family physician, internist or
endocrinologist to manage the systemic diabetes. The ophthalmologist should communicate with
the attending physician. (Level A: III Recommendation) (AAO, 2003)

43

12/31/2007

Measure #20: Perioperative Care: Timing of Antibiotic Prophylaxis – Ordering Physician
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic parenteral antibiotics, who have an order for prophylactic antibiotic to
be given within one hour (if fluoroquinolone or vancomycin, two hours), prior to the surgical incision
(or start of procedure when no incision is required)
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo surgical procedures with the indications for prophylactic antibiotics. There is
no diagnosis associated with this measure. It is anticipated that clinicians who perform the listed
surgical procedures as specified in the denominator coding will submit this measure.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure. If multiple surgical procedures were performed on the same date of
service and submitted on the same claim form, it is not necessary for the same clinician to submit
the CPT Category II code with each procedure. However, if multiple NPIs are reporting this
measure on the same claim, each NPI should report the quality-data code.
When reporting the measure, submit the listed CPT procedure code and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Surgical patients who have an order for prophylactic antibiotic to be given within one hour (if
fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when
no incision is required)
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that antibiotic is to be given within one hour (if
fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of
procedure when no incision is required) OR documentation that antibiotic has been given
within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision
(or start of procedure when no incision is required).
Note: In the event surgery is delayed, as long as the patient is redosed (if clinically
appropriate) the numerator coding should be applied.

44

12/31/2007

Numerator Coding:
Table 1A: The antimicrobial drugs listed below are considered prophylactic antibiotics for
the purposes of this measure.
• Ampicillin/sulbactam
• Cefuroxime
• Gentamicin
• Aztreonam
• Ciprofloxacin
• Levofloxacin
• Clindamycin
• Metronidazole
• Cefazolin
• Cefmetazole
• Ertapenem
• Moxifloxacin
• Cefotetan
• Erythromycin base
• Neomycin
• Cefoxitin
• Gatifloxacin
• Vancomycin
Documentation of Order for Prophylactic Antibiotic (written order, verbal order, or
standing order/protocol)
CPT II 4047F: Documentation of order for prophylactic antibiotics to be given within one
hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of
procedure when no incision is required)
OR
Documentation that Prophylactic Antibiotic has been Given within One Hour Prior to
the Surgical Incision (or start of procedure when no incision is required)
CPT II 4048F: Documentation that prophylactic antibiotic was given within one hour (if
fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure
when no incision is required)
OR

OR

Order for Prophylactic Antibiotic not Given for Medical Reasons
Append a modifier (1P) to CPT Category II code 4047F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not ordering antibiotics to be given within
one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or
start of procedure when no incision is required)
Order for Administration of Prophylactic Antibiotic not Given, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4047F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Prophylactic antibiotics were not ordered to be given or given within one hour (if
fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of
procedure when no incision is required), reason not otherwise specified

DENOMINATOR:
All surgical patients aged 18 years and older undergoing procedures with the indications for
prophylactic parenteral antibiotics

45

12/31/2007

Denominator Coding:
A CPT procedure code for surgical procedures for which prophylactic antibiotics are
indicated is required to identify patients for denominator inclusion.
SURGICAL PROCEDURE
Integumentary

CPT CODE
15734, 15738, 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364,
19366, 19367, 19368, 19369
21346, 21347, 21348, 21422, 21423, 21432, 21433,
21435, 21436
21454, 21461, 21462, 21465, 21470
22325, 22612, 22630, 22800, 22802, 22804, 63030,
63042
27125, 27130, 27132, 27134, 27137, 27138
27235, 27236, 27244, 27245, 27269, 27758, 27759,
27766, 27769, 27792, 27814
27440, 27441, 27442, 27443, 27445, 27446, 27447
31360, 31365, 31367, 31368, 31370, 31375, 31380,
31382, 31390, 31395
33877, 33880, 33881, 33883, 33886, 33891, 34800,
34802, 34803, 34804, 34805, 34825, 34830, 34831,
34832, 34900, 35081, 35091, 35102, 35131, 35141,
35151, 35601, 35606, 35612, 35616, 35621, 35623,
35626, 35631, 35636, 35637, 35638, 35642, 35645,
35646, 35647, 35650, 35651, 35654, 35656, 35661,
35663, 35665, 35666, 35671, 36830
38115
41130, 41135, 41140, 41145, 41150, 41153, 41155
43045, 43100, 43101, 43107, 43108, 43112, 43113,
43116, 43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43300, 43305, 43310, 43312, 43313,
43320, 43324, 43325, 43326, 43330, 43331, 43340,
43341, 43350, 43351, 43352, 43360, 43361, 43400,
43401, 43405, 43410, 43415, 43420, 43425, 43496
43500, 43501, 43502, 43510, 43520, 43600, 43605,
43610, 43611, 43620, 43621, 43622, 43631, 43632,
43633, 43634, 43640, 43641, 43653, 43800, 43810,
43820, 43825, 43830, 43831, 43832, 43840, 43843,
43845, 43846, 43847, 43848, 43850, 43855, 43860,
43865, 43870
44005, 44010, 44020, 44021, 44050, 44055, 44100,
44120, 44125, 44126, 44127, 44130, 44132, 44133,
44135, 44136
43880, 44025, 44110, 44111, 44140, 44141, 44143,
44144, 44145, 44146, 44147, 44150, 44151, 44155,
44156, 44157, 44158, 44160, 44202, 44204, 44205,

Le Fort Fractures
Mandibular Fracture
Spine
Hip Reconstruction
Trauma (Fractures)
Knee Reconstruction
Laryngectomy
Vascular

Spleen and Lymph Nodes
Glossectomy
Esophagus

Stomach

Small Intestine
Colon and Rectum

46

12/31/2007

44206, 44207, 44208, 44210, 44211, 44212, 44300,
44310, 44312, 44314, 44316, 44320, 44322, 44340,
44345, 44346, 44602, 44603, 44604, 44605, 44615,
44620, 44625, 44626, 44640, 44650, 44660, 44661,
44700, 44950, 51597
45108, 45110, 45111, 45112, 45113, 45114, 45116,
45119, 45120, 45121, 45123, 45126, 45130, 45135,
45136, 45150, 45160, 45170, 45190, 45500, 45505,
45520, 45540, 45541, 45550, 45560, 45562, 45563,
45800, 45805, 45820, 45825
47133, 47135, 47136, 47140, 47141, 47142
47420, 47425, 47460, 47480, 47560, 47561, 47570,
47600, 47605, 47610, 47612, 47620, 47700, 47701,
47711, 47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47802, 47900
48020, 48100, 48120, 48140, 48145, 48146, 48148,
48150, 48152, 48153, 48154, 48155, 48500, 48510,
48511, 48520, 48540, 48545, 48547, 48548, 48550,
48554, 48556
49215, 49568
50300, 50320, 50340, 50360, 50365, 50370, 50380
58150, 58152, 58180, 58200, 58210, 58260, 58262,
58263, 58267, 58270, 58275, 58280, 58285, 58290,
58291, 58292, 58293, 58294
61520, 61526, 61530, 61591, 61595, 61596, 61598,
61606, 61616, 61618, 61619, 69720, 69955, 69960,
69970
69930
22524, 22554, 22558, 22600, 22612, 22630, 35301,
61154, 61312, 61313, 61315, 61510, 61512, 61518,
61548, 61697, 61700, 61750, 61751, 61867, 62223,
62230, 63015, 63020, 63030, 63042, 63045, 63047,
63056, 63075, 63081, 63267, 63276
33120, 33130, 33140, 33141, 33202, 33250, 33251,
33256, 33261, 33305, 33315, 33321, 33322, 33332,
33335, 33400, 33401, 33403, 33404, 33405, 33406,
33410, 33411, 33413, 33416, 33422, 33425, 33426,
33427, 33430, 33460, 33463, 33464, 33465, 33475,
33496, 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33521, 33522, 33523, 33530,
33533, 33534, 33535, 33536, 33542, 33545, 33548,
33572, 35211, 35241, 35271
33203, 33206, 33207, 33208, 33212, 33213, 33214,
33215, 33216, 33217, 33218, 33220, 33222, 33223,
33224, 33225, 33226, 33233, 33234, 33235, 33236,
33237, 33238, 33240, 33241, 33243, 33244, 33249,

Anus and Rectum

Hepatic Surgery
Biliary Surgery

Pancreas

Abdomen, Peritoneum, & Omentum
Renal Transplant
Gynecologic Surgery
Acoustic Neuroma
Cochlear Implants
Neurological Surgery

Cardiothoracic Surgery

Cardiothoracic (Pacemaker)

47

12/31/2007

33254, 33255
51550, 51555, 51565, 51570, 51575, 51580, 51585,
51590, 51595, 51596, 51920, 51925, 52450, 52601,
52612, 52614, 52620, 52630, 52647, 52648, 52649,
54401, 54405, 54406, 54408, 54410, 54415, 54416,
55801, 55810, 55812, 55815, 55821, 55831, 55840,
55842, 55845
19272, 21627, 21632, 21740, 21750, 21805, 21825,
31760, 31766, 31770, 31775, 31786, 31805, 32095,
32100, 32110, 32120, 32124, 32140, 32141, 32150,
32215, 32220, 32225, 32310, 32320, 32402, 32440,
32442, 32445, 32480, 32482, 32484, 32486, 32488,
32491, 32500, 32501, 32800, 32810, 32815, 32900,
32905, 32906, 32940, 33020, 33025, 33030, 33031,
33050, 33300, 33310, 33320, 34051, 35021, 35216,
35246, 35276, 35311, 35481, 35526, 37616, 38381,
38746, 38747, 39000, 39010, 39200, 39220, 39545,
39561, 60521, 60522, 64746
27702, 27703, 27704, 27870, 28192, 28193, 28293,
28296, 28299, 28300, 28306, 28307, 28308, 28309,
28310, 28320, 28322, 28415, 28420, 28445, 28465,
28485, 28505, 28525, 28531, 28555, 28585, 28615,
28645, 28675, 28705, 28715, 28725, 28730, 28735,
28737, 28740, 28750, 28755, 28760

Genitourinary Surgery

General Thoracic Surgery

Foot & Ankle

RATIONALE:
The appropriate timing of administration of prophylactic antibiotics has been demonstrated to
reduce the incidence of surgical wound infections. Specifying the time of administration in the order
is critical as available evidence suggests that the drug should be received within one hour before
incision for maximum antimicrobial effect.
CLINICAL RECOMMENDATION STATEMENTS:
The anti-infective drug should ideally be given within 30 minutes to 1 hour before the initial incision
to ensure its presence in an adequate concentration in the targeted tissues. For most procedures,
scheduling administration at the time of induction of anesthesia ensures adequate concentrations
during the period of potential contamination. Exceptions: cesarean procedures (after cross
clamping of the umbilical cord); colonic procedures (starting 19 hours before the scheduled time of
surgery). (ASHP)
Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However,
when a fluoroquinolone or vancomycin is indicated, the infusion should begin within 120 minutes
before incision to prevent antibiotic-associated reactions. Although research has demonstrated that
administration of the antimicrobial at the time of anesthesia induction is safe and results in adequate
serum and tissue drug levels at the time of incision, there was no consensus that the infusion must
be completed before incision. (SIPGWW)

48

12/31/2007

Measure #21: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second
Generation Cephalosporin
DESCRIPTION:
Percentage of surgical patients aged 18 years and older undergoing procedures with the
indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order
for cefazolin OR cefuroxime for antimicrobial prophylaxis
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo surgical procedures with the indications for a first or second generation
cephalosporin prophylactic antibiotic. There is no diagnosis associated with this measure. It is
anticipated that clinicians who perform the listed surgical procedures as specified in the
denominator coding will submit this measure.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure. If multiple surgical procedures were performed on the same date of
service and submitted on the same claim form, it is not necessary for the same clinician to submit
the CPT Category II code with each procedure. However, if multiple NPIs are reporting this
measure on the same claim, each NPI should report the quality-data code.
When reporting the measure, submit the listed CPT procedure codes and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Surgical patients who had an order for cefazolin OR cefuroxime for antimicrobial prophylaxis
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) for cefazolin or cefuroxime for antimicrobial prophylaxis
OR documentation that cefazolin or cefuroxime was given.
Note: In the event surgery is delayed, as long as the patient is redosed (if clinically
appropriate) the numerator coding should be applied.
Numerator Coding:
Acceptable First and Second Generation Cephalosporin Prophylactic Antibiotics
First generation cephalosporin: cefazolin
Second generation cephalosporin: cefuroxime

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OR

OR

Documentation of order for cefazolin OR cefuroxime for antimicrobial prophylaxis
(written order, verbal order, or standing order/protocol)
CPT II 4041F: Documentation of order for cefazolin OR cefuroxime for antimicrobial
prophylaxis
Note: CPT Category II code 4041F is provided for antibiotic ordered or antibiotic given.
Report CPT Category II code 4041F if cefazolin OR cefuroxime was given for antimicrobial
prophylaxis.
Order for First or Second Generation Cephalosporin not Ordered for Medical
Reasons
Append a modifier (1P) to CPT Category II code 4041F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not ordering cefazolin OR cefuroxime for
antimicrobial prophylaxis
Order for First or Second Generation Cephalosporin not Ordered, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4041F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Order for cefazolin OR cefuroxime for antimicrobial prophylaxis was not
documented, reason not otherwise specified

DENOMINATOR:
All surgical patients aged 18 years and older undergoing procedures with the indications for a first
or second generation cephalosporin prophylactic antibiotic
Denominator Coding:
A CPT procedure code for surgical procedures with indications for first or second
generation cephalosporin prophylactic antibiotic is required to identify patients for
denominator inclusion.
SURGICAL PROCEDURE
Integumentary
Spine
Hip Reconstruction
Trauma (Fractures)
Knee Reconstruction
Vascular

CPT CODE
15734, 15738, 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364,
19366, 19367, 19368, 19369
22325, 22612, 22630, 22800, 22802, 22804, 63030,
63042
27125, 27130, 27132, 27134, 27137, 27138
27235, 27236, 27244, 27245, 27269, 27758, 27759,
27766, 27769, 27792, 27814
27440, 27441, 27442, 27443, 27445, 27446, 27447
33877, 33880, 33881, 33883, 33886, 33891, 34800,
34802, 34803, 34804, 34805, 34825, 34830, 34831,
34832, 34900, 35081, 35091, 35102, 35131, 35141,
35151, 35601, 35606, 35612, 35616, 35621, 35623,

50

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Spleen and Lymph Nodes
Esophagus

Stomach

Small Intestine
Hepatic Surgery
Biliary Surgery

Pancreas

Abdomen, Peritoneum &
Omentum
Renal Transplant
Gynecologic Surgery
Neurological Surgery

Cardiothoracic Surgery

35626, 35631, 35636, 35637, 35638, 35642, 35645,
35646, 35647, 35650, 35651, 35654, 35656, 35661,
35663, 35665, 35666, 35671, 36830
38100, 38101, 38115, 38120
43045, 43100, 43101, 43107, 43108, 43112, 43113,
43116, 43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43280, 43300, 43305, 43310, 43312,
43313, 43320, 43324, 43325, 43326, 43330, 43331,
43340, 43341, 43350, 43351, 43352, 43360, 43361,
43400, 43401, 43405, 43410, 43415, 43420, 43425,
43496
43500, 43501, 43502, 43510, 43520, 43600, 43605,
43610, 43611, 43620, 43621, 43622, 43631, 43632,
43633, 43634, 43640, 43641, 43651, 43652, 43653,
43800, 43810, 43820, 43825, 43830, 43831, 43832,
43840, 43843, 43845, 43846, 43847, 43848, 43850,
43855, 43860, 43865, 43870, 43880
44005, 44010, 44020, 44021, 44025, 44050, 44055,
44100, 44110, 44111, 44120, 44125, 44126, 44127,
44130, 44132, 44133, 44135, 44136
47133, 47135, 47136, 47140, 47141, 47142
47420, 47425, 47460, 47480, 47490, 47510, 47511,
47525, 47530, 47560, 47561, 47570, 47600, 47605,
47610, 47612, 47620, 47630, 47700, 47701, 47711,
47712, 47715, 47720, 47721, 47740, 47741, 47760,
47765, 47780, 47785, 47800, 47802, 47900
48001, 48020, 48100, 48102, 48120, 48140, 48145,
48146, 48148, 48150, 48152, 48153, 48154, 48155,
48500, 48510, 48511, 48520, 48540, 48545, 48547,
48548, 48550, 48554, 48556
49000, 49002, 49010, 49180, 49203, 49204, 49205,
49215
50300, 50320, 50340, 50360, 50365, 50370, 50380
58150, 58152, 58180, 58200, 58210, 58260, 58262,
58263, 58267, 58270, 58275, 58280, 58285, 58290,
58291, 58292, 58293, 58294
22524, 22554, 22558, 22600, 22612, 22630, 35301,
61154, 61312, 61313, 61315, 61510, 61512, 61518,
61548, 61697, 61700, 61750, 61751, 61867, 62223,
62230, 63015, 63020, 63030, 63042, 63045, 63047,
63056, 63075, 63081, 63267, 63276
33120, 33130, 33140, 33141, 33202, 33250, 33251,
33256, 33261, 33305, 33315, 33321, 33322, 33332,
33335, 33400, 33401, 33403, 33404, 33405, 33406,
33410, 33411, 33413, 33416, 33422, 33425, 33426,
33427, 33430, 33460, 33463, 33464, 33465, 33475,

51

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Cardiothoracic
(Pacemaker)
General Thoracic Surgery

Foot & Ankle

33496, 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33521, 33522, 33523, 33530,
33533, 33534, 33535, 33536, 33542, 33545, 33548,
33572, 35211, 35241, 35271, 35820
33203, 33254, 33255
19272, 21627, 21632, 21740, 21750, 21805, 21825,
31760, 31766, 31770, 31775, 31786, 31805, 32035,
32036, 32095, 32100, 32110, 32120, 32124, 32140,
32141, 32150, 32200, 32215, 32220, 32225, 32310,
32320, 32402, 32440, 32442, 32445, 32480, 32482,
32484, 32486, 32488, 32491, 32500, 32501, 32540,
32601, 32602, 32603, 32604, 32605, 32606, 32650,
32651, 32652, 32653, 32654, 32655, 32656, 32657,
32658, 32659, 32660, 32661, 32662, 32663, 32664,
32665, 32800, 32810, 32815, 32900, 32905, 32906,
32940, 33020, 33025, 33030, 33031, 33050, 33300,
33310, 33320, 34051, 35021, 35216, 35246, 35276,
35311, 35481, 35526, 37616, 38381, 38746, 38747,
39000, 39010, 39200, 39220, 39545, 39561, 60521,
60522, 64746
27702, 27703, 27704, 27870, 28192, 28193, 28293,
28296, 28299, 28300, 28306, 28307, 28308, 28309,
28310, 28320, 28322, 28415, 28420, 28445, 28465,
28485, 28505, 28525, 28531, 28555, 28585, 28615,
28645, 28675, 28705, 28715, 28725, 28730, 28735,
28737, 28740, 28750, 28755, 28760

RATIONALE:
Current published evidence supports the use of either cefazolin, a first generation cephalosporin,
or cefuroxime, a second generation cephalosporin, for many surgical procedures, in the absence of
β-lactam allergy. An alternative antimicrobial regimen may be appropriate depending on the
antimicrobial susceptibility pattern in an individual institution (potentially a medical reason for
excluding patients treated at that institution from this measure.)
CLINICAL RECOMMENDATION STATEMENTS:
For most procedures, cefazolin should be the agent of choice because of its relatively long duration
of action, its effectiveness against the organisms most commonly encountered in surgery, and its
relatively low cost. (ASHP)
In operations for which cephalosporins represent appropriate prophylaxis, alternative antimicrobials
should be provided to those with a high likelihood of serious adverse reaction or allergy on the
basis of patient history or diagnostic tests such as skin testing.

52

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The preferred antimicrobials for prophylaxis in patients undergoing hip or knee arthroplasty are
cefazolin and cefuroxime. Vancomycin or clindamycin may be used in patients with serious allergy
or adverse reactions to β-lactams.
The recommended antimicrobials for cardiothoracic and vascular operations include cefazolin or
cefuroxime. For patients with serious allergy or adverse reaction to β-lactams, vancomycin is
appropriate, and clindamycin may be an acceptable alternative. (SIPGWW)

53

12/31/2007

Measure #22: Perioperative Care: Discontinuation of Prophylactic Antibiotics (NonCardiac Procedures)
DESCRIPTION:
Percentage of non-cardiac surgical patients aged 18 years and older undergoing procedures with
the indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an
order for discontinuation of prophylactic antibiotics within 24 hours of surgical end time
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo non-cardiac surgical procedures with the indications for prophylactic
antibiotics. There is no diagnosis associated with this measure. It is anticipated that clinicians who
perform the listed surgical procedures as specified in the denominator coding will submit this
measure.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the denominator. CPT Category II codes are used to report the numerator of
the measure. If multiple surgical procedures were performed on the same date of service and
submitted on the same claim form, it is not necessary for the same clinician to submit the CPT
Category II code with each procedure. However, if multiple NPIs are reporting this measure on the
same claim, each NPI should report the quality-data code.
When reporting the measure, submit the listed CPT procedure codes and the appropriate CPT
Category II code(s) OR the CPT Category II code(s) with the modifier. The modifiers allowed for
this measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Non-cardiac surgical patients who have an order for discontinuation of prophylactic antibiotics
within 24 hours of surgical end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic antibiotic is to be
discontinued within 24 hours of surgical end time OR specifying a course of antibiotic
administration limited to that 24-hour period (e.g., “to be given every 8 hours for three
doses”) OR documentation that prophylactic antibiotic was discontinued within 24 hours of
surgical end time.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

54

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Numerator Coding:
Documentation of order for discontinuation of prophylactic antibiotics (written
order, verbal order, or standing order/protocol) within 24 hours of surgical end time
(Two CPT II codes [4049F & 4046F] are required on the claim form to submit this
category)
CPT II 4049F: Documentation that order was given to discontinue prophylactic antibiotics
within 24 hours of surgical end time, non-cardiac procedure
Note: CPT Category II code 4049F is provided for documentation that antibiotic
discontinuation was ordered or that antibiotic discontinuation was accomplished.
Report CPT Category II code 4049F if antibiotics were discontinued within 24
hours.
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
OR

Prophylactic Antibiotics not Discontinued for Medical Reasons
(Two CPT II codes [4049F-1P & 4046F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II code 4049F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4049F with 1P: Documentation of medical reason(s) for not discontinuing prophylactic
antibiotics within 24 hours of surgical end time
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
OR
If patient is not eligible for this measure because patient did not receive
prophylactic antibiotics within specified timeframe, report:
(One CPT II code [4042F] is required on the claim form to submit this category)
CPT II 4042F: Documentation that prophylactic antibiotics were neither given within 4
hours prior to surgical incision nor given intraoperatively

OR

Prophylactic Antibiotics not Discontinued, Reason not Specified
(Two CPT II codes [4049F-8P & 4046F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4049F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4049F with 8P: Order was not given to discontinue prophylactic antibiotics within 24
hours of surgical end time, non-cardiac procedure, reason not otherwise specified

55

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AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
DENOMINATOR:
All non-cardiac surgical patients undergoing procedures with the indications for prophylactic
antibiotics AND who received a prophylactic antibiotic.
Denominator Instructions: For the purpose of this measure of antibiotic discontinuation,
patients may be counted as having “received a prophylactic antibiotic” if the antibiotic was
received within 4 hours prior to the surgical incision (or start of procedure when no incision
is required) or intraoperatively.
Denominator Coding:
A CPT procedure code for non-cardiac surgical procedures for which prophylactic
antibiotics are indicated is required to identify patients for denominator inclusion.
SURGICAL PROCEDURE
Integumentary
Le Fort Fractures
Mandibular Fracture
Spine
Hip Reconstruction
Trauma (Fractures)
Knee Reconstruction
Laryngectomy
Vascular

Glossectomy
Esophagus

CPT CODE
15734, 15738, 19260, 19271, 19272, 19301, 19302,
19303, 19304, 19305, 19306, 19307, 19361, 19364,
19366, 19367, 19368, 19369
21346, 21347, 21348, 21422, 21423, 21432, 21433,
21435, 21436
21454, 21461, 21462, 21465, 21470
22325, 22612, 22630, 22800, 22802, 22804, 63030,
63042
27125, 27130, 27132, 27134, 27137, 27138
27235, 27236, 27244, 27245, 27269, 27758, 27759,
27766, 27769, 27792, 27814
27440, 27441, 27442, 27443, 27445, 27446, 27447
31360, 31365, 31367, 31368, 31370, 31375, 31380,
31382, 31390, 31395
33877, 33880, 33881, 33883, 33886, 33891, 34800,
34802, 34803, 34804, 34805, 34825, 34830, 34831,
34832, 34900, 35081, 35091, 35102, 35131, 35141,
35151, 35601, 35606, 35612, 35616, 35621, 35623,
35626, 35631, 35636, 35637, 35638, 35642, 35645,
35646, 35647, 35650, 35651, 35654, 35656, 35661,
35663, 35665, 35666, 35671, 36830
41130, 41135, 41140, 41145, 41150, 41153, 41155
43045, 43100, 43101, 43107, 43108, 43112, 43113,
43116, 43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43300, 43305, 43310, 43312, 43313,
43320, 43324, 43325, 43326, 43330, 43331, 43340,
43341, 43350, 43351, 43352, 43360, 43361, 43400,
43401, 43405, 43410, 43415, 43420, 43425, 43496

56

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Stomach

Small Intestine
Colon and Rectum

Anus and Rectum

Biliary Surgery

Pancreas

Abdomen, Peritoneum, &
Omentum
Renal Transplant
Gynecologic Surgery
Acoustic Neuroma
Cochlear Implants
Neurological Surgery

Cardiothoracic
(Pacemaker)

43500, 43501, 43502, 43510, 43520, 43600, 43605,
43610, 43611, 43620, 43621, 43622, 43631, 43632,
43633, 43634, 43640, 43641, 43653, 43800, 43810,
43820, 43825, 43830, 43831, 43832, 43840, 43843,
43845, 43846, 43847, 43848, 43850, 43855, 43860,
43865, 43870
44005, 44010, 44020, 44021, 44050, 44055, 44100,
44120, 44125, 44126, 44127, 44130, 44132, 44133,
44135, 44136
43880, 44025, 44110, 44111, 44140, 44141, 44143,
44144, 44145, 44146, 44147, 44150, 44151, 44155,
44156, 44157, 44158, 44160, 44202, 44204, 44205,
44206, 44207, 44208, 44210, 44211, 44212, 44300,
44310, 44312, 44314, 44316, 44320, 44322, 44340,
44345, 44346, 44615, 44620, 44625, 44626, 44640,
44650, 44660, 44661, 44700, 44950, 51597
45108, 45110, 45111, 45112, 45113, 45114, 45116,
45119, 45120, 45121, 45123, 45126, 45130, 45135,
45136, 45150, 45160, 45170, 45190, 45500, 45505,
45520, 45540, 45541, 45550, 45560, 45562, 45563,
45800, 45805, 45820, 45825
47420, 47425, 47460, 47480, 47560, 47561, 47570,
47600, 47605, 47610, 47612, 47620, 47700, 47701,
47711, 47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47802, 47900
48020, 48100, 48120, 48140, 48145, 48146, 48148,
48150, 48152, 48153, 48154, 48155, 48500, 48510,
48511, 48520, 48540, 48545, 48547, 48548, 48550,
48554, 48556
49215, 49568
50300, 50320, 50340, 50360, 50365, 50370, 50380
58150, 58152, 58180, 58200, 58210, 58260, 58262,
58263, 58267, 58270, 58275, 58280, 58285, 58290,
58291, 58292, 58293, 58294
61520, 61526, 61530, 61591, 61595, 61596, 61598,
61606, 61616, 61618, 61619, 69720, 69955, 69960,
69970
69930
22524, 22554, 22558, 22600, 22612, 22630, 35301,
61154, 61312, 61313, 61315, 61510, 61512, 61518,
61548, 61697, 61700, 61750, 61751, 61867, 62223,
62230, 63015, 63020, 63030, 63042, 63045, 63047,
63056, 63075, 63081, 63267, 63276
33203, 33206, 33207, 33208, 33212, 33213, 33214,
33215, 33216, 33217, 33218, 33220, 33222, 33223,

57

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General Thoracic Surgery

Foot & Ankle

33224, 33225, 33226, 33233, 33234, 33235, 33236,
33237, 33238, 33240, 33241, 33243, 33244, 33249,
33254, 33255
19272, 21627, 21632, 21740, 21750, 21805, 21825,
31760, 31766, 31770, 31775, 31786, 31805, 32095,
32100, 32110, 32120, 32124, 32140, 32141, 32150,
32215, 32220, 32225, 32310, 32320, 32402, 32440,
32442, 32445, 32480, 32482, 32484, 32486, 32488,
32491, 32500, 32501, 32800, 32810, 32815, 32900,
32905, 32906, 32940, 33020, 33025, 33030, 33031,
33050, 33300, 33310, 33320, 34051, 35021, 35216,
35246, 35276, 35311, 35481, 35526, 37616, 38381,
38746, 38747, 39000, 39010, 39200, 39220, 39545,
39561, 60521, 60522, 64746
27702, 27703, 27704, 27870, 28192, 28193, 28293,
28296, 28299, 28300, 28306, 28307, 28308, 28309,
28310, 28320, 28322, 28415, 28420, 28445, 28465,
28485, 28505, 28525, 28531, 28555, 28585, 28615,
28645, 28675, 28705, 28715, 28725, 28730, 28735,
28737, 28740, 28750, 28755, 28760

RATIONALE:
There is no evidence there is added benefit of prolonged prophylactic antibiotic use. Prolonged use
may increase antibiotic resistant organisms.
CLINICAL RECOMMENDATION STATEMENTS:
At a minimum, antimicrobial coverage must be provided from the time of incision to closure of the
incision. For most procedures, the duration of antimicrobial prophylaxis should be 24 hours or less,
with the exception of cardiothoracic procedures (up to 72 hours’ duration) and ophthalmic
procedures (duration not clearly established). (ASHP)
Prophylactic antimicrobials should be discontinued within 24 hours after the operation. (SIPGWW)

58

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Measure #23: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When
Indicated in ALL Patients)
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing procedures for which VTE prophylaxis
is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low-Dose
Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis
to be given within 24 hours prior to incision time or within 24 hours after surgery end time
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
all patients who undergo surgical procedures for which VTE prophylaxis is indicated. There is no
diagnosis associated with this measure. It is anticipated that clinicians who perform the listed
surgical procedures as specified in the denominator coding will submit this measure.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure. If multiple surgical procedures were performed on the same date of
service and submitted on the same claim form, it is not necessary for the same clinician to submit
the CPT Category II code with each procedure. However, if multiple NPIs are reporting this
measure on the same claim, each NPI should report the quality-data code.
When reporting the measure, submit the listed CPT procedures and the appropriate CPT Category
II code OR the CPT Category II code with the modifier. The modifiers allowed for this measure are:
1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Surgical patients who had an order for LMWH, LDUH, adjusted-dose warfarin, fondaparinux or
mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after
surgery end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) for VTE prophylaxis OR documentation that VTE
prophylaxis was given.
Definition: Mechanical prophylaxis does not include TED hose.
Numerator Coding:
Appropriate VTE Prophylaxis Ordered
CPT II 4044F: Documentation that an order was given for venous thromboembolism (VTE)
prophylaxis to be given within 24 hours prior to incision time or 24 hours after surgery end
time
Note: A single CPT Category II code is provided for VTE prophylaxis is ordered or
VTE prophylaxis is given. If VTE prophylaxis is given, report 4044F.

59

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OR

OR

VTE Prophylaxis not Ordered for Medical Reasons
Append a modifier (1P) to CPT Category II code 4044F above to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for patient not receiving any form of VTE
prophylaxis (LMWH, LDUH, adjusted-dose warfarin, fondaparinux or mechanical
prophylaxis) within 24 hours prior to incision time or 24 hours after surgery end time
VTE Prophylaxis not Ordered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4044F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Order was not given for venous thromboembolism (VTE) prophylaxis to be given
within 24 hours prior to incision time or 24 hours after surgery end time, reason not
otherwise specified

DENOMINATOR:
All surgical patients aged 18 years and older undergoing procedures for which VTE prophylaxis is
indicated in all patients
Denominator Coding:
A CPT procedure code for surgical procedures for which VTE prophylaxis is indicated is
required to identify patients for denominator inclusion.
SURGICAL PROCEDURE
Neurological Surgery

Hip Reconstruction
Knee Reconstruction
Genitourinary Surgery

Gynecologic Surgery

CPT CODE
22558, 22600, 22612, 22630, 61313, 61510,
61512, 61518, 61548, 61697, 61700, 62230,
63015, 63020, 63047, 63056, 63081, 63267,
63276
27125, 27130, 27132, 27134, 27137, 27138
27440, 27441, 27442, 27443, 27445, 27446,
27447
50020, 50220, 50225, 50230, 50234, 50236,
50240, 50320, 50340, 50360, 50365, 50370,
50380, 50543, 50545, 50546, 50547, 50548,
50715, 50722, 50725, 50727, 50728, 50760,
50770, 50780, 50782, 50783, 50785, 50800,
50810, 50815, 50820, 50947, 50948, 51550,
51555, 51565, 51570, 51575, 51580, 51585,
51590, 51595, 51596, 51597, 51800, 51820,
51900, 51920, 51925, 51960, 55810, 55812,
55815, 55821, 55831, 55840, 55842, 55845,
55866
56630, 56631, 56632, 56633, 56634, 56637,
56640, 58200, 58210, 58240, 58285, 58951,
58953, 58954, 58956

60

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Hip Fracture Surgery
General Surgery

27235, 27236, 27244, 27245, 27269
19260, 19271, 19272, 19301, 19302, 19303,
19304, 19305, 19306, 19307, 19316, 19318,
19324, 19325, 19328, 19330, 19342, 19350,
19355, 19357, 19361, 19364, 19366, 19367,
19368, 19369, 19370, 19371, 19380, 38100,
38101, 38115, 38120, 38571, 38572, 38700,
38720, 38724, 38740, 38745, 38747, 38760,
38765, 38770, 38780, 39501, 39502, 39503,
39520, 39530, 39531, 39540, 39541, 39545,
39560, 39561, 43020, 43030, 43045, 43100,
43101, 43107, 43108, 43112, 43113, 43116,
43117, 43118, 43121, 43122, 43123, 43124,
43130, 43135, 43280, 43300, 43305, 43310,
43312, 43313, 43314, 43320, 43324, 43325,
43326, 43330, 43331, 43340, 43341, 43350,
43351, 43352, 43360, 43361, 43400, 43401,
43405, 43410, 43415, 43420, 43425, 43496,
43500, 43501, 43502, 43510, 43520, 43605,
43610, 43611, 43620, 43621, 43622, 43631,
43632, 43633, 43634, 43640, 43641, 43644,
43645, 43651, 43652, 43653, 43770, 43771,
43772, 43773, 43774, 43800, 43810, 43820,
43825, 43830, 43832, 43840, 43843, 43845,
43846, 43847, 43848, 43850, 43855, 43860,
43865, 43870, 43880, 43886, 43887, 43888,
44005, 44010, 44020, 44021, 44025, 44050,
44055, 44110, 44111, 44120, 44125, 44126,
44127, 44130, 44140, 44141, 44143, 44144,
44145, 44146, 44147, 44150, 44151, 44155,
44156, 44157, 44158, 44160, 44180, 44186,
44187, 44188, 44202, 44204, 44205, 44206,
44207, 44208, 44210, 44211, 44212, 44227,
44300, 44310, 44312, 44314, 44316, 44320,
44322, 44340, 44345, 44346, 44602, 44603,
44604, 44605, 44615, 44620, 44625, 44626,
44640, 44650, 44660, 44661, 44680, 44700,
44800, 44820, 44850, 44900, 44950, 44960,
44970, 45000, 45020, 45100, 45108, 45110,
45111, 45112, 45113, 45114, 45116, 45119,
45120, 45121, 45123, 45126, 45130, 45135,
45136, 45150, 45160, 45170, 45190, 45395,
45397, 45400, 45402, 45500, 45505, 45550,
45560, 45562, 45563, 45800, 45805, 45820,
45825, 46715, 46716, 46730, 46735, 46740,
46742, 46744, 46746, 46748, 46750, 46751,

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46753, 46754, 46760, 46761, 46762, 47010,
47100, 47120, 47122, 47125, 47130, 47135,
47136, 47140, 47141, 47142, 47300, 47350,
47360, 47361, 47362, 47370, 47371, 47380,
47381, 47382, 47400, 47420, 47425, 47460,
47480, 47500, 47505, 47560, 47561, 47562,
47563, 47564, 47570, 47600, 47605, 47610,
47612, 47620, 47630, 47700, 47701, 47711,
47712, 47715, 47720, 47721, 47740, 47741,
47760, 47765, 47780, 47785, 47800, 47801,
47802, 47900, 48000, 48001, 48020, 48100,
48105, 48120, 48140, 48145, 48146, 48148,
48150, 48152, 48153, 48154, 48155, 48500,
48510, 48520, 48540, 48545, 48547, 48548,
48554, 48556, 49000, 49002, 49010, 49020,
49040, 49060, 49203, 49204, 49205, 49215,
49220, 49250, 49255, 49320, 49321, 49322,
49323, 49560, 49561, 49565, 49566, 49570,
50320, 50340, 50360, 50365, 50370, 50380,
60200, 60210, 60212, 60220, 60225, 60240,
60252, 60254, 60260, 60270, 60271, 60280,
60281, 60500, 60502, 60505, 60520, 60521,
60522, 60540, 60545, 60600, 60605, 60650
RATIONALE:
This measure addresses VTE risk based on surgical procedure. VTE prophylaxis is appropriate for
all patients undergoing these procedures regardless of individual patient thromboembolic risk
factors.
Additional work is needed to determine if a physician-level measure for VTE prophylaxis can be
developed to address individual patient thromboembolic risk factors, in addition to procedural risk,
without creating data collection burden. Many of these procedures are done in hospitals and ASCs,
but quite a few are performed in the physician's office. There are many reasons for the differences
in the site of service, including that breast lesions and breast tissue varies considerably. Some
women have a small breast and a small lesion that can be expeditiously treated as a minor office
procedure done in 20 minutes under local anesthesia. In this instance, the evidence for DVT
prophylaxis is simply not present. Other patients have small or large lesions located in difficult
positions within a dense complex breast. In this instance, the patients have long procedures under
general anesthesia. Both of these instances can occur within the same CPT code. It should be
noted that the number of medical exclusions for these codes will likely be much higher than other
codes to account for the variation in major and minor procedures within the same CPT code.
Duration of VTE prophylaxis is not specified in the measure due to varying guideline
recommendations for different patient populations.

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CLINICAL RECOMMENDATION STATEMENTS:
Recommend that mechanical methods of prophylaxis be used primarily in patients who are at high
risk of bleeding (Grade 1C+) or as an adjunct to anticoagulant-based prophylaxis (Grade 2A).
Recommend against the use of aspirin alone as prophylaxis against VTE for any patient group
(Grade 1A).
Recommend consideration of renal impairment when deciding on doses of LMWH, fondaparinux,
the direct thrombin inhibitors, and other antithrombotic drugs that are cleared by the kidneys,
particularly in elderly patients and those who are at high risk for bleeding (Grade 1C+).
Moderate-risk general surgery patients are those patients undergoing a nonmajor procedure and
are between the ages of 40 and 60 years or have additional risk factors, or those patients who
are undergoing major operations and are < 40 years of age with no additional risk factors.
Recommend prophylaxis with LDUH, 5,000 U bid or LMWH <= 3,400 U once daily (both Grade
1A).
Higher-risk general surgery patients are those undergoing nonmajor surgery and are > 60 years of
age or have additional risk factors, or patients undergoing major surgery who are > 40 years of
age or have additional risk factors. Recommend thromboprophylaxis with LDUH, 5,000 U tid or
LMWH, > 3,400 U daily (both Grade 1A).
Recommend that thromboprophylaxis be used in all major gynecologic surgery patients (Grade
1A).
For patients undergoing major, open urologic procedures, recommend routine prophylaxis with
LDUH twice daily or three times daily (Grade 1A).
Patients undergoing major orthopedic surgery, which includes hip and knee arthroplasty and hip
fracture repair, represent a group that is at particularly high risk for VTE, and routine
thromboprophylaxis has been the standard of care for > 15 years. Elective total hip replacement:
routine use of LMWH, fondaparinux, or adjusted-dose VKA (all Grade 1A). Elective total knee
arthroplasty: routine thromboprophylaxis using LMWH, fondaparinux, or adjusted-dose VKA (all
Grade 1A). Hip fracture surgery: routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+),
adjusted-dose VKA (Grade 2B), or LDUH (Grade 1B).
For major orthopedic surgical procedures, recommend that a decision about the timing of the
initiation of pharmacologic prophylaxis be based on the efficacy-to-bleeding tradeoffs for that
particular agent (Grade 1A). For LMWH, there are only small differences between starting
preoperatively or postoperatively, both options acceptable (Grade 1A).
Recommend that thromboprophylaxis be routinely used in patients undergoing major neurosurgery
(Grade 1A). (ACCP)

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Measure #24: Osteoporosis: Communication with the Physician Managing Ongoing Care
Post-Fracture
DESCRIPTION:
Percentage of patients aged 50 years and older treated for a hip, spine, or distal radial fracture with
documentation of communication with the physician managing the patient’s on-going care that a
fracture occurred and that the patient was or should be tested or treated for osteoporosis
INSTRUCTIONS:
This measure is to be reported after each occurrence of a fracture during the reporting period.
Patients with a fracture of the hip, spine, or distal radius should have documentation in the medical
record of communication from the clinician treating the fracture to the clinician managing the
patient’s on-going care that the fracture occurred and that the patient was or should be tested or
treated for osteoporosis. If multiple fractures occurring on the same date of service are submitted
on the same claim form, only one instance of reporting will be counted. Claims data will be
analyzed to determine unique occurrences. Documentation must indicate that communication to
the clinician managing the on-going care of the patient occurred within three months of treatment
for the fracture. The CPT Category II code should be reported during the episode of care (e.g.,
treatment of the fracture). The reporting of the code and documentation of communication do not
need to occur simultaneously. It is anticipated that clinicians who treat the hip, spine or distal radial
fracture will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, CPT procedure codes, and patient demographics
(age, gender, etc.) are used to identify patients who are included in the measure’s denominator.
CPT Category II codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
CPT procedure codes, and the appropriate CPT Category II code OR the CPT Category II code
with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients with documentation of communication with the physician managing the patient’s on-going
care that a fracture occurred and that the patient was or should be tested or treated for
osteoporosis
Definition: Communication may include: Documentation in the medical record indicating
that the clinician treating the fracture communicated (e.g., verbally, by letter, DXA report
was sent) with the clinician managing the patient’s on-going care OR a copy of a letter in
the medical record outlining whether the patient was or should be treated for osteoporosis.

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Numerator Coding:
Post Fracture Care Communication Documented
CPT II 5015F: Documentation of communication that a fracture occurred and that the
patient was or should be tested or treated for osteoporosis
OR

OR

Post Fracture Care not Communicated for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 5015F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not communicating with physician
managing on-going care of patient that a fracture occurred and that the patient was or
should be tested or treated for osteoporosis
• 2P: Documentation of patient reason(s) for not communicating that a fracture occurred
and that the patient was or should be tested or treated for osteoporosis with physician
managing on-going care of patient
Post Fracture Care not Communicated, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 5015F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: No documentation of communication that a fracture occurred and that the patient
was or should be tested or treated for osteoporosis, reason not otherwise specified

DENOMINATOR:
All patients aged 50 years and older treated for hip, spine, or distal radial fracture
Denominator Coding:
An ICD-9 diagnosis code for hip, spine or distal radial fracture and a CPT E/M service
code or a CPT procedure code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 733.12, 733.13, 733.14, 805.00, 805.01, 805.02, 805.03, 805.04,
805.05, 805.06, 805.07, 805.08, 805.10, 805.11, 805.12, 805.13, 805.14, 805.15, 805.16,
805.17, 805.18, 805.2, 805.4, 805.6, 805.8, 813.40, 813.41, 813.42, 813.44, 813.45,
813.50, 813.51, 813.52, 813.54, 820.00, 820.01, 820.02, 820.03, 820.09, 820.10, 820.11,
820.13, 820.20, 820.21, 820.22, 820.8, 820.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
OR
CPT procedure codes: 22305, 22310, 22315, 22318, 22319, 22325, 22326, 22327,
22520, 22521, 22523, 22524, 25600, 25605, 25606, 25607, 25608, 25609, 27230, 27232,
27235, 27236, 27238, 27240, 27244, 27245, 27246, 27248

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RATIONALE:
Patients who experience fragility fractures should either be treated or screened for the presence of
osteoporosis. Although the fracture may be treated by the orthopedic surgeon, the testing and/or
treatment is likely to be under the responsibility of the physician providing on-going care. It is
important the physician providing on-going care for the patient be made aware the patient has
sustained a non-traumatic fracture. There is a high degree of variability and consensus by experts
of what constitutes a fragility fracture and predictor of an underlying problem of osteoporosis. The
work group determined that only those fractures, which have the strongest consensus and
evidence that they are predictive of osteoporosis, should be included in the measure at this time.
We anticipate that the list of fractures will expand as further evidence is published supporting the
inclusion of other fractures.
CLINICAL RECOMMENDATION STATEMENTS:
The most important risk factors for osteoporosis-related fractures are a prior low-trauma fracture as
an adult and a low BMD in patients with or without fractures. (AACE)
BMD measurement should be performed in all women 40 years old or older who have sustained a
fracture. (AACE)
The decision to measure bone density should follow an individualized approach. It should be
considered when it will help the patient decide whether to institute treatment to prevent
osteoporotic fracture. It should also be considered in patients receiving glucocorticoid therapy for 2
months or more and patients with other conditions that place them at high risk for osteoporotic
fracture. (NIH)
The most commonly used measurement to diagnose osteoporosis and predict fracture risk is
based on assessment of BMD by dual-energy X-ray absorptiometry (DXA). (NIH) Measurements of
BMD made at the hip predict hip fracture better than measurements made at other sites while BMD
measurement at the spine predicts spine fracture better than measures at other sites. (NIH)
The single most powerful predictor of a future osteoporotic fracture is the presence of previous
such fractures. (AGA)

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Measure #28: Aspirin at Arrival for Acute Myocardial Infarction (AMI)
DESCRIPTION:
Percentage of patients, regardless of age, with an emergency department discharge diagnosis of
AMI who had documentation of receiving aspirin within 24 hours before emergency department
arrival or during emergency department stay
INSTRUCTIONS:
This measure is to be reported each time during the reporting period a patient has been discharged
from the emergency department with a diagnosis of AMI. Patients who are discharged from the
emergency department with a diagnosis of AMI should have documentation in the medical record
of having received aspirin 24 hours before emergency department arrival or during emergency
department stay. It is anticipated that clinicians who provide care in the emergency department will
submit this measure. The Part B claim form place-of-service field must indicate that the encounter
has taken place in the emergency department.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT E/M service codes are used to identify patients who are included
in the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who had documentation of receiving aspirin within 24 hours before emergency department
arrival or during emergency department stay

OR

OR

Numerator Coding:
Aspirin Received or Taken 24 Hours Before Emergency Department Arrival or
During Emergency Department Stay
CPT II 4084F: Aspirin received within 24 hours before emergency department arrival or
during emergency department stay
Aspirin not Received or Taken 24 Hours Before Emergency Department Arrival or
During Emergency Department Stay for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4084F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not receiving or taking aspirin within 24
hours before emergency department arrival or during emergency department stay
• 2P: Documentation of patient reason(s) for not receiving or taking aspirin within 24
hours before emergency department arrival or during emergency department stay

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Aspirin not Received or Taken 24 Hours Before Emergency Department Arrival or
During Emergency Department Stay, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4084F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Aspirin was not received within 24 hours before emergency department arrival or
during emergency department stay, reason not otherwise specified
DENOMINATOR:
All patients, regardless of age, with an emergency department discharge diagnosis of acute
myocardial infarction
Denominator Coding:
An ICD-9 diagnosis code for acute myocardial infarction and a CPT E/M service code are
required to identify patients for denominator inclusion. The Part B claim form place-ofservice field must indicate emergency department.
ICD-9 diagnosis codes: 410.01, 410.11, 410.21, 410.31, 410.41, 410.51, 410.61, 410.71,
410.81, 410.91
AND
CPT E/M service codes: 99281, 99282, 99283, 99284, 99285, 99291
AND
Place of Service Indicator: 23
RATIONALE:
The emergency physician should document that the patient received aspirin no matter where or
when the aspirin was taken.
CLINICAL RECOMMENDATION STATEMENTS:
Aspirin should be chewed by patients who have not taken aspirin before presentation with STEMI.
The initial dose should be 162 mg (Level A) to 325 mg (Level C). Although some trials have used
enteric-coated aspirin for initial dosing, more rapid buccal absorption occurs with non–entericcoated aspirin formulations. (ACC/AHA)

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Measure #30: Perioperative Care: Timing of Prophylactic Antibiotic – Administering
Physician
DESCRIPTION:
Percentage of surgical patients aged 18 and older who have an order for a parenteral antibiotic to
be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision
(or start of procedure when no incision is required) for whom administration of prophylactic
antibiotic has been initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to
the surgical incision (or start of procedure when no incision is required)
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo surgical procedures with an order for prophylactic antibiotics. It is anticipated
that clinicians who provide anesthesia care for surgical procedures with an order for prophylactic
antibiotics will submit this measure.
This measure is reported using CPT Category II codes:
A CPT Category II code and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. Only CPT Category II codes are used to report
this measure.
When reporting the measure, submit the appropriate CPT Category II code OR the CPT Category
II code with the modifier. The reporting modifier allowed for this measure is: 8P- reasons not
otherwise specified. There are no allowable performance exclusions for this measure.
NUMERATOR:
Surgical patients for whom administration of a prophylactic antibiotic has been initiated within one
hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of
procedure when no incision is required)
Numerator Instructions: This measure seeks to identify the timely administration of
prophylactic antibiotic. This administration should begin within one hour (if fluoroquinolone
or vancomycin, two hours) prior to surgical incision.
Numerator Coding:
Table 2A: The antimicrobial drugs listed below are considered prophylactic antibiotics for
the purposes of this measure.
• Ampicillin/sulbactam
• Cefuroxime
• Gentamicin
• Aztreonam
• Ciprofloxacin
• Levofloxacin
• Cefazolin
• Clindamycin
• Metronidazole
• Cefmetazole
• Ertapenem
• Moxifloxacin
• Cefotetan
• Erythromycin base
• Neomycin
• Cefoxitin
• Gatifloxacin
• Vancomycin

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Prophylactic Antibiotic Given
CPT II 4048F: Documentation that prophylactic antibiotic was given within one hour (if
fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure
when no incision is required)
OR

Prophylactic Antibiotic not Given, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4048F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Prophylactic antibiotic was not given within one hour (if fluoroquinolone or
vancomycin, two hours) prior to the surgical incision (or start of procedure when no
incision is required), reason not otherwise specified

DENOMINATOR:
All surgical patients aged 18 years and older who have an order for a parenteral antibiotic to be
given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or
start of procedure when no incision is required)
Denominator Instructions: For denominator inclusion, there must be documentation of
order (written order, verbal order, or standing order/protocol) specifying that prophylactic
parenteral antibiotic is to be given within one hour (if fluoroquinolone or vancomycin, two
hours) prior to the surgical incision (or start of procedure when no incision is required).
Denominator Coding:
A CPT Category II code for a parenteral antibiotic order is required to identify patients for
denominator inclusion.
CPT II 4047F: Documentation of order for prophylactic antibiotics to be given within one
hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of
procedure when no incision is required)
RATIONALE:
The appropriate timing of administration of prophylactic antibiotics has been demonstrated to
reduce the incidence of surgical wound infections. Available evidence suggests that although most
surgical patients receive a prophylactic antibiotic, many do not receive the drug within one hour
before incision as recommended.
CLINICAL RECOMMENDATION STATEMENTS:
The anti-infective drug should ideally be given within 30 minutes to 1 hour before the initial incision
to ensure its presence in an adequate concentration in the targeted tissues. For most procedures,
scheduling administration at the time of induction of anesthesia ensures adequate concentrations
during the period of potential contamination. Exceptions: cesarean procedures (after cross
clamping of the umbilical cord); colonic procedures (starting 19 hours before the scheduled time of
surgery). (ASHP)
Infusion of the first antimicrobial dose should begin within 60 minutes before incision. However,
when a fluoroquinolone or vancomycin is indicated, the infusion should begin within 120 minutes
before incision to prevent antibiotic-associated reactions. Although research has demonstrated that

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administration of the antimicrobial at the time of anesthesia induction is safe and results in adequate
serum and tissue drug levels at the time of incision, there was no consensus that the infusion must
be completed before incision. (SIPGWW)

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Measure #31: Stroke and Stroke Rehabilitation: Deep Vein Thrombosis Prophylaxis (DVT)
for Ischemic Stroke or Intracranial Hemorrhage
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial
hemorrhage who received DVT prophylaxis by end of hospital day two
INSTRUCTIONS:
This measure is to be reported during each hospital stay when a patient is under active treatment
for ischemic stroke or intracranial hemorrhage during the reporting period. Part B claims data will
be analyzed to determine a hospital stay. If multiple qualifying diagnoses are submitted on the
same claim form, only one instance of reporting will be counted. It is anticipated that clinicians who
care for patients with a diagnosis of ischemic stroke or intracranial hemorrhage in the hospital
setting will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who received Deep Vein Thrombosis (DVT) prophylaxis by the end of hospital day two
Definition: For purposes of this measure, DVT prophylaxis can include Low Molecular
Weight Heparin (LMWH), Low-Dose Unfractionated Heparin (LDUH), intravenous Heparin,
low-dose subcutaneous heparin, or intermittent pneumatic compression devices.

OR

OR

Numerator Coding:
DVT Prophylaxis Received
CPT II 4070F: Deep Vein Thrombosis (DVT) prophylaxis received by end of hospital day 2
DVT Prophylaxis not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4070F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not receiving DVT Prophylaxis by end of
hospital day 2, including physician documentation that patient is ambulatory
• 2P: Documentation of patient reason(s) for not receiving DVT Prophylaxis by end of
hospital day 2

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DVT Prophylaxis not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4070F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Deep Vein Thrombosis (DVT) prophylaxis was not received by end of hospital day
2, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage
Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke or intracranial hemorrhage and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01,
434.11, 434.91
AND
CPT E/M service codes: 99221, 99222, 99223, 99251, 99252, 99253, 99254, 99255,
99291
RATIONALE:
Patients on bed rest are at high risk for deep vein thrombosis. DVT prevention is important for all
patients who have suffered a stroke or an intracranial hemorrhage and may have decreased
mobility. The intent of this measure is to assure that adequate DVT prophylaxis is received for
either diagnosis. As noted in the clinical recommendation statements, the appropriate type of
prophylaxis differs by diagnosis. Anticoagulants are generally contraindicated in patients with
intracranial hemorrhage. These patients are still at risk for DVT so they should receive prophylaxis
with mechanical devices. Low-dose subcutaneous heparin may be initiated on the second day after
onset of the hemorrhage.
CLINICAL RECOMMENDATION STATEMENTS:
Subcutaneous unfractionated heparin, LMW heparins, and heparinoids may be considered for DVT
prophylaxis in at-risk patients with acute ischemic stroke, recognizing that nonpharmacologic
treatments for DVT prevention also exist. (Coull, AAN/ASA, 2002) (Grade A)
The use of intermittent external compression stockings or aspirin for patients who cannot receive
anticoagulants is strongly recommended to prevent deep vein thrombosis among immobilized
patients. (Adams, ASA, 2003) (Grades A and B)
For acute stroke patients with restricted mobility, we recommend prophylactic low-dose
subcutaneous heparin or low-molecular-weight heparins or heparinoid. (Grade 1A) In patients with
an acute ICH, we recommend the initial use of intermittent pneumatic compression for the
prevention of DVT and PE. (Grade 1C+) In stable patients, we suggest low-dose subcutaneous
heparin may be initiated as soon as the second day after the onset of the hemorrhage. (Grade 2C)
(Albers, ACCP, 2004)

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Measure #32: Stroke and Stroke Rehabilitation: Discharged on Antiplatelet Therapy
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient
ischemic attack (TIA) who were prescribed antiplatelet therapy at discharge
INSTRUCTIONS:
This measure is to be reported for patients under active treatment for ischemic stroke or TIA at
discharge from a hospital during the reporting period. Part B claims data will be analyzed to
determine the hospital discharge. If multiple qualifying diagnoses are submitted on the same claim
form, only one instance of reporting will be counted. It is anticipated that clinicians who care for
patients with a diagnosis of ischemic stroke or TIA in the hospital setting will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who were prescribed antiplatelet therapy at discharge
Definition: Antiplatelet therapy: aspirin, combination of aspirin and extended-release
dipyridamole, clopidogrel, ticlopidine

OR

Numerator Coding:
Antiplatelet Therapy Prescribed
CPT II 4073F: Oral antiplatelet therapy prescribed at discharge
Antiplatelet Therapy Prescription not Prescribed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4073F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing oral antiplatelet therapy at
discharge
• 2P: Documentation of patient reason(s) for not prescribing oral antiplatelet therapy at
discharge

OR

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Antiplatelet Therapy Prescription not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4073F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Oral antiplatelet therapy was not prescribed at discharge, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or transient ischemic
attack (TIA)
Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke or transient ischemic attack (TIA) and a CPT
E/M service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,
434.91, 435.0, 435.1, 435.2, 435.3, 435.8, 435.9
AND
CPT E/M service codes: 99238, 99239, 99251, 99252, 99253, 99254, 99255
RATIONALE:
Following a stroke, patients should be prescribed antiplatelet therapy to decrease the risk of
additional strokes.
CLINICAL RECOMMENDATION STATEMENTS:
We recommend that every patient who has experienced a noncardioembolic (atherothrombotic,
lacunar, or cryptogenic) stroke or TIA and has no contraindication receives an antiplatelet agent
regularly to reduce the risk of recurrent stroke and other vascular events. Aspirin, 50 to 325 mg qd;
the combination of aspirin, 25 mg, and extended-release dipyridamole, 200 mg bid; or clopidogrel,
75 mg qd, are all acceptable options for initial therapy. (Albers, ACCP, 2001) (Grade 1A)
For patients with noncardioembolic ischemic stroke or TIA, antiplatelet agents rather than oral
anticoagulation are recommended to reduce the risk of recurrent stroke and other cardiovascular
events. (Sacco, ASA, 2006) (Class I, Level of Evidence: A)
Aspirin (50 to 325 mg/d), the combination of aspirin and extended-release dipyridamole, and
clopidogrel are all acceptable options for initial therapy. (Sacco, ASA, 2006) (Class IIa, Level of
Evidence: A)

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Measure #33: Stroke and Stroke Rehabilitation: Anticoagulant Therapy Prescribed for
Atrial Fibrillation at Discharge
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or transient
ischemic attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation who
were prescribed an anticoagulant at discharge
INSTRUCTIONS:
This measure is to be reported for patients under active treatment for ischemic stroke or TIA with
documented atrial fibrillation at discharge from a hospital during the reporting period. Part B claims
data will be analyzed to determine the hospital discharge. If multiple qualifying diagnoses are
submitted on the same claim form, only one instance of reporting will be counted. It is anticipated
that clinicians who care for patients with a diagnosis of ischemic stroke or TIA in the hospital
setting will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who were prescribed an anticoagulant at discharge
Definitions:
• Persistent Atrial Fibrillation: recurrent atrial fibrillation, not self-terminating or
terminated electrically or pharmacologically
• Paroxysmal Atrial Fibrillation: recurrent atrial fibrillation, self-terminating
• Permanent Atrial Fibrillation: long-standing atrial fibrillation (> 1 year), cardioversion
failed or not attempted
Numerator Coding:
Anticoagulant Prescribed
CPT II 4075F: Anticoagulant therapy prescribed at discharge
OR

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Anticoagulant Prescription not Received for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4075F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing anticoagulant therapy at
discharge
• 2P: Documentation of patient reason(s) for not prescribing anticoagulant therapy at
discharge
OR

Anticoagulant Prescription not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4075F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Anticoagulant therapy was not prescribed at discharge, reason not otherwise
specified

DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or transient ischemic
attack (TIA) with documented permanent, persistent, or paroxysmal atrial fibrillation
Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke or transient ischemic attack (TIA) and atrial
fibrillation and a CPT E/M service code are required to identify patients for denominator
inclusion.
ICD-9 diagnosis codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,
434.91, 435.0, 435.1, 435.2, 435.3, 435.8, 435.9
AND
ICD-9 diagnosis code: 427.31
AND
CPT E/M service codes: 99238, 99239, 99251, 99252, 99253, 99254, 99255
RATIONALE:
Patients with atrial fibrillation (permanent, persistent, or paroxysmal) and stroke should be
prescribed an anticoagulant to prevent recurrent strokes.
CLINICAL RECOMMENDATION STATEMENTS:
Administer antithrombotic therapy (oral anticoagulation or aspirin) to all patients with AF, except
those with lone AF, to prevent thromboembolism. (ACC/AHA/ESC, 2001)(Class I, Level of
Evidence: A)
We recommend that clinicians use long-term oral anticoagulation (target INR of 2.5; range, 2.0 to
3.0) for prevention of stroke in atrial fibrillation patients who have suffered a recent stroke or TIA.
Oral anticoagulation is also beneficial for prevention of recurrent stroke in patients with several
other high-risk cardiac sources. (Albers, ACCP, 2001) (Grade 1A)
For patients with ischemic stroke or TIA with persistent or paroxysmal AF, anticoagulation with
adjusted-dose warfarin (target INR, 2.5; range 2.0 to 3.0) is recommended. (Sacco, ASA, 2006)
(Class I, Level of Evidence: A)

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Measure #34: Stroke and Stroke Rehabilitation: Tissue Plasminogen Activator (t-PA)
Considered
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke whose time
from symptom onset to arrival is less than 3 hours who were considered for t-PA administration
INSTRUCTIONS:
This measure is to be reported during each hospital stay for all patients under active treatment for
ischemic stroke during the reporting period. Part B claims data will be analyzed to determine a
hospital stay. If multiple qualifying diagnoses are submitted on the same claim form, only one
instance of reporting will be counted. It is anticipated that clinicians who care for patients with a
diagnosis of ischemic stroke in the hospital setting will submit this measure.
This measure is reported using CPT Category II codes:
ICD 9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are
no allowable performance exclusions for this measure.
NUMERATOR:
Patients who were considered for t-PA administration (given t-PA or documented reasons for
patient not being a candidate for therapy)
Definition: For purposes of this measure, patients “considered for t-PA administration”
includes patients to whom t-PA was given or patients for whom reasons for not being a
candidate for t-PA therapy are documented.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
t-PA Administration or Consideration Documented
(Two CPT II codes [4077F & 1065F] are required on the claim form to submit this
category)
CPT II 4077F: Documentation that tissue plasminogen activator (t-PA) administration was
considered
AND
CPT II 1065F: Ischemic stroke symptom onset of less than 3 hours prior to arrival

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OR

OR

If patient is not eligible for this measure because ischemic stroke symptom onset ≥
3 hours prior to arrival at hospital, report:
(One CPT II code [1066F] is required on the claim form to submit this category)
CPT II 1066F: Ischemic stroke symptom onset greater than or equal to 3 hours prior to
arrival
t-PA Administration or Consideration not Documented, Reason not Specified
(Two CPT II codes [4077F-8P & 1065F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4077F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4077F with 8P: Tissue plasminogen activator (t-PA) administration was not
considered, reason not otherwise specified
AND
CPT II 1065F: Ischemic stroke symptom onset of less than 3 hours prior to arrival

DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke whose time from
symptom onset to arrival is less than 3 hours
Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11,
434.91
AND
CPT E/M service codes: 99221, 99222, 99223, 99251, 99252, 99253, 99254, 99255,
99291
RATIONALE:
Patients who arrive at the hospital within 3 hours of stroke symptom onset should be considered for
t-PA therapy.
CLINICAL RECOMMENDATION STATEMENTS:
We recommend administration of IV tPA in a dose of 0.9 mg/kg (maximum of 90 mg), with 10% of
the total dose given as an initial bolus and the remainder infused over 60 minutes for eligible
patients, provided that treatment is initiated within 3 hours of clearly defined symptom onset. We
recommend strict adherence to eligibility criteria for the use of IV tPA based on the NINDS trial
protocol. (Inclusion Criteria: Age ≥ 18 years, clinical diagnosis of stroke with a clinically meaningful
neurologic deficit, clearly defined time of onset of < 180 minutes before treatment, and a baseline
CT showing no evidence of intracranial hemorrhage. (Albers, ACCP, 2001) (Grade 1A)

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Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is strongly recommended for carefully
selected patients who can be treated within 3 hours of onset of ischemic stroke. (Adams, ASA,
2003) (Grade A)

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Measure #35: Stroke and Stroke Rehabilitation: Screening for Dysphagia
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial
hemorrhage who underwent a dysphagia screening process before taking any foods, fluids or
medication by mouth
INSTRUCTIONS:
This measure is to be reported during each hospital stay for all patients under active treatment for
ischemic stroke or intracranial hemorrhage during the reporting period. Part B claims data will be
analyzed to determine a hospital stay. If multiple qualifying diagnoses are submitted on the same
claim form, only one instance of reporting will be counted. It is anticipated that clinicians who care
for patients with a diagnosis of ischemic stroke or intracranial hemorrhage in the hospital setting
will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who underwent a dysphagia screening process before taking any foods, fluids or
medication by mouth
Definition: Dysphagia Screening: use of a tested and validated dysphagia screening tool
(e.g., Burke dysphagia screening test, 3 oz. water swallow test, Mann assessment of
swallowing ability [MASA], standardized bedside swallowing assessment [SSA]) OR a
dysphagia screening tool approved by the hospital's speech/language pathology (SLP)
services.
Numerator Instructions: For purposes of this measure, patients “who receive any food,
fluids or medication by mouth” may be identified by the absence of an NPO (nothing by
mouth) order
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Dysphagia Screening Conducted
(Two CPT II codes [6010F & 6015F] are required on the claim form to submit this
category)

OR

CPT II 6010F: Dysphagia screening conducted prior to order for or receipt of any foods,
fluids or medication by mouth
AND
CPT II 6015F: Patient receiving or eligible to receive food, fluids or medication by mouth
Dysphagia Screening not Conducted for Medical Reasons
(Two CPT II codes [6010F-1P & 6015F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II code 6010F to report documented
circumstances that appropriately exclude patients from the denominator.
• 6010F with 1P: Documentation of medical reason(s) for not conducting dysphagia
screening prior to taking any foods, fluids or medication by mouth
AND
CPT II 6015F: Patient receiving or eligible to receive food, fluids or medication by mouth
OR
If patient is not eligible for this measure because patient is NPO, report:
(One CPT II code [6020F] is required on the claim form to submit this category)

OR

CPT II 6020F: NPO (nothing by mouth) ordered
Dysphagia Screening not Conducted, Reason not Specified
(Two CPT II codes [6010F-8P & 6015F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 6010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 6010 with 8P: Dysphagia screening was not conducted prior to order for or receipt of
any foods, fluids or medication by mouth, reason not otherwise specified
AND
CPT II 6015F: Patient receiving or eligible to receive food, fluids or medication by mouth

DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage who receive any food, fluids or medication by mouth

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Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke or intracranial hemorrhage and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01,
434.11, 434.91
AND
CPT E/M service codes: 99221, 99222, 99223, 99251, 99252, 99253, 99254, 99255
RATIONALE:
All patients should have their swallowing evaluated prior to receiving food, fluids or oral
medications to help prevent aspiration. The evaluation should be performed with a validated or
hospital-approved dysphagia screening tool; a routine cranial nerve examination is not sufficient.
CLINICAL RECOMMENDATION STATEMENTS:
Recommend that all patients have their swallow screened before initiating oral intake of fluids or
food, utilizing a simple valid bedside testing protocol. (VA/DoD, 2003) (Evidence II-2, Grade B)

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Measure #36: Stroke and Stroke Rehabilitation: Consideration of Rehabilitation Services
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ischemic stroke or intracranial
hemorrhage for whom consideration of rehabilitation services is documented
INSTRUCTIONS:
This measure is to be reported for patients under active treatment for ischemic stroke or
intracranial hemorrhage a minimum of once during each hospital stay occurring during the
reporting period. Part B claims data will be analyzed to determine the hospital stay. If multiple
qualifying diagnoses are submitted on the same claim form, only one instance of reporting will be
counted. It is anticipated that clinicians who care for patients with a diagnosis of ischemic stroke or
intracranial hemorrhage in the hospital setting will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients for whom consideration of rehabilitation services (ordered rehabilitation or documented
that rehabilitation was not indicated) is documented
Definition: For purposes of this measure, “consideration of rehabilitation services”
includes an order for rehabilitation services or documentation that rehabilitation was not
indicated.
Numerator Coding:
Rehabilitation Services Ordered or Considered
CPT II 4079F: Documentation that rehabilitation services were considered
OR

Rehabilitation Services not Ordered or Considered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4079F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Rehabilitation services were not considered, reason not otherwise specified

DENOMINATOR:
All patients aged 18 years and older with the diagnosis of ischemic stroke or intracranial
hemorrhage

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Denominator Coding:
An ICD-9 diagnosis code for ischemic stroke or intracranial hemorrhage and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 431, 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01,
434.11, 434.91
AND
CPT E/M service codes: 99238, 99239, 99251, 99252, 99253, 99254, 99255
RATIONALE:
All patients should be considered for rehabilitation services to meet the individual patient needs.
CLINICAL RECOMMENDATION STATEMENTS:
Strongly recommend that patients in need of rehabilitation services have access to a setting with a
coordinated and organized rehabilitation care team that is experienced in providing stroke services.
The coordination and organization of inpatient post–acute stroke care will improve patient outcome.
(VA/DoD, 2003)

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Measure #39: Screening or Therapy for Osteoporosis for Women Aged 65 Years and Older
DESCRIPTION:
Percentage of female patients aged 65 years and older who have a central dual-energy X-ray
absorptiometry (DXA) measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once during the reporting period for patients seen
during the reporting period. Female patients aged 65 years and older should have a central DXA
measurement ordered or performed at least once since the time they turned 60 years or have
pharmacologic therapy prescribed to prevent or treat osteoporosis. There is no diagnosis
associated with this measure. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using G-codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who had a central DXA measurement ordered or performed at least once since age 60 or
pharmacologic therapy prescribed within 12 months
Definitions:
• Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or
SERMs (raloxifene).
• "Prescribed" includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
Numerator Coding:
Central DXA Measurement Ordered or Performed or Pharmacologic Therapy
Prescribed
G8399: Patient with central Dual-energy X-Ray Absorptiometry (DXA) results documented
or ordered or pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed

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OR

OR

Central DXA Measurement not Ordered or Performed or Pharmacologic Therapy not
Prescribed for Documented Reasons
G8401: Clinician documented that patient was not an eligible candidate for screening or
therapy for osteoporosis for women measure
Central DXA Measurement not Ordered or Performed or Pharmacologic Therapy not
Prescribed, Reason not Specified
G8400: Patient with central Dual-energy X-Ray Absorptiometry (DXA) results not
documented or not ordered or pharmacologic therapy (other than minerals/vitamins) for
osteoporosis not prescribed

DENOMINATOR:
All female patients aged 65 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Patients with elevated risk for osteoporosis should have the diagnosis of osteoporosis excluded or
be on treatment of osteoporosis.
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older
be screened routinely for osteoporosis. (B Recommendation) (USPSTF)
The USPSTF recommends that routine screening begin at age 60 for women at increased risk for
osteoporotic fractures. Use of risk factors, particularly increasing age, low weight, and non-use of
estrogen replacement, to screen younger women may identify high-risk women. (B
Recommendation) (USPSTF)
BMD measurement should be performed in all women beyond 65 years of age. Dual x-ray
absorptiometry of the lumbar spine and proximal femur provides reproducible values at important
sites of osteoporosis-associated fracture. These sites are preferred for baseline and serial
measurements. (AACE)
The most important risk factors for osteoporosis-related fractures are a prior low-trauma fracture as
an adult and a low BMD in patients with or without fractures. (AACE)
BMD testing should be performed on:
• All women aged 65 and older regardless of risk factors
• Younger postmenopausal women with one or more risk factors (other than being white,
postmenopausal, and female)
• Postmenopausal women who present with fractures (NQF)

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The decision to test for BMD should be based on an individual’s risk profile. Testing is never
indicated unless the results could influence a treatment decision. (NQF)
Markers of greater osteoporosis and fracture risk include older age, hypogonadism, corticosteroid
therapy, and established cirrhosis. (Level B Evidence) (NQF)
The single most powerful predictor of a future osteoporotic fracture is the presence of previous
such fractures. (NQF)
Pharmacologic therapy should be initiated to reduce fracture risk in women with:
• BMD T-scores below -2.0 by central dual x-ray absorptiometry (DXA) with no risk factors
• BMD T-scores below -1.5 by central dual x-ray absorptiometry (DXA) with one or more risk
factors
• A prior vertebral or hip fracture (NQF)
The decision to measure bone density should follow an individualized approach. It should be
considered when it will help the patient decide whether to institute treatment to prevent
osteoporotic fracture. It should also be considered in patients receiving glucocorticoid therapy for 2
months or more and patients with other conditions that place them at high risk for osteoporotic
fracture. (NIH)
The most commonly used measurement to diagnose osteoporosis and predict fracture risk is
based on assessment of BMD by dual-energy X-ray absorptiometry (DXA). (NIH)
Measurements of BMD made at the hip predict hip fracture better than measurements made at
other sites while BMD measurement at the spine predicts spine fracture better than measures at
other sites. (NIH)

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Measure #40: Osteoporosis: Management Following Fracture
DESCRIPTION:
Percentage of patients aged 50 years and older with fracture of the hip, spine or distal radius who
had a central dual-energy X-ray absorptiometry (DXA) measurement ordered or performed or
pharmacologic therapy prescribed
INSTRUCTIONS:
This measure is to be reported after each occurrence of a fracture during the reporting period.
Patients with a fracture of the hip, spine, or distal radius should have a central DXA measurement
ordered or performed or pharmacologic therapy prescribed. The management (DXA ordered or
performed or pharmacologic therapy prescribed) should occur within three months of the initial visit
with the reporting clinician following the fracture. If multiple fractures occurring on the same date of
service are submitted on the same claim form, only one instance of reporting will be counted.
Claims data will be analyzed to determine unique occurrences. Patients with documentation of
prior central DXA measurement or already receiving pharmacologic therapy would automatically
meet the intent of this measure. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, CPT procedure codes, and patient demographics
(age, gender, etc.) are used to identify patients who are included in the measure’s denominator.
CPT Category II codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
CPT procedure codes, and the appropriate CPT Category II code OR the CPT Category II code
with the modifier. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient
reasons, 3P- system reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who had a central DXA measurement ordered or performed or pharmacologic therapy
prescribed
Numerator Instruction: Modifiers may be appended to any of the CPT Category II codes
for medical reasons, patient reasons, system reasons, or reasons not otherwise specified.
Definitions:
• Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or
SERMs (raloxifene).

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•

OR

OR

"Prescribed" includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.

Numerator Coding:
Central DXA Measurement Ordered or Results Documented or Pharmacologic
Therapy Prescribed
CPT II 3096F: Central Dual-energy X-Ray Absorptiometry (DXA) ordered
OR
CPT II 3095F: Central Dual-energy X-Ray Absorptiometry (DXA) results documented
OR
CPT II 4005F: Pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed
Central DXA Measurement not Ordered or Results not Documented or
Pharmacologic Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II codes 3096F or 3095F or 4005F to
report documented circumstances that appropriately exclude patients from the
denominator.
• 1P: Documentation of medical reason(s) for not ordering or performing a central dual
energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic
therapy for osteoporosis
• 2P: Documentation of patient reason(s) for not ordering or performing a central dual
energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic
therapy for osteoporosis
• 3P: Documentation of system reason(s) for not ordering or performing a central dual
energy X-ray absorptiometry (DXA) measurement or not prescribing pharmacologic
therapy for osteoporosis
Central DXA Measurement not Ordered or Results not Documented or
Pharmacologic Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3096F or 3095F or 4005F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
• 8P: Central dual energy X-ray absorptiometry (DXA) measurement was not ordered or
performed or pharmacologic therapy for osteoporosis was not prescribed, reason not
otherwise specified

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DENOMINATOR:
All patients aged 50 years and older with a fracture of the hip, spine, or distal radius
Denominator Coding:
An ICD-9 diagnosis code for hip, spine or distal radial fracture and a CPT E/M service
code or a CPT procedure code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 733.12, 733.13, 733.14, 805.00, 805.01, 805.02, 805.03, 805.04,
805.05, 805.06, 805.07, 805.08, 805.10, 805.11, 805.12, 805.13, 805.14, 805.15, 805.16,
805.17, 805.18, 805.2, 805.4, 805.6, 805.8, 813.40, 813.41, 813.42, 813.44, 813.45,
813.50, 813.51, 813.52, 813.54, 820.00, 820.01, 820.02, 820.03, 820.09, 820.10, 820.11,
820.13, 820.20, 820.21, 820.22, 820.8, 820.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
OR
CPT procedure codes: 22305, 22310, 22315, 22318, 22319, 22325, 22326, 22327,
22520, 22521, 22523, 22524, 25600, 25605, 25606, 25607, 25608, 25609, 27230, 27232,
27235, 27236, 27238, 27240, 27244, 27245, 27246, 27248
RATIONALE:
Patients with a history of fracture should have a baseline bone mass measurement and/or receive
treatment for osteoporosis. Given that the majority of osteoporotic fractures occur in patients with a
diagnosis of osteoporosis by bone mass measurement, exclusion of osteoporosis by bone mass
testing does not preclude treatment of osteoporosis in a patient with a history of fracture. There is a
high degree of variability and consensus by experts of what constitutes a fragility fracture and
predictor of an underlying problem of osteoporosis. The work group determined that only those
fractures, which have the strongest consensus and evidence that they are predictive of
osteoporosis, should be included in the measure at this time. We anticipate that the list of fractures
will expand as further evidence is published supporting the inclusion of other fractures.
CLINICAL RECOMMENDATION STATEMENTS:
The most important risk factors for osteoporosis-related fractures are a prior low-trauma fracture as
an adult and a low BMD in patients with or without fractures. (AACE)
BMD measurement should be performed in all women 40 years old or older who have sustained a
fracture. (AACE)
The single most powerful predictor of a future osteoporotic fracture is the presence of previous
such fractures. (AACE)
The decision to measure bone density should follow an individualized approach. It should be
considered when it will help the patient decide whether to institute treatment to prevent
osteoporotic fracture. It should also be considered in patients receiving glucocorticoid therapy for 2
months or more and patients with other conditions that place them at high risk for osteoporotic
fracture. (NIH)

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The most commonly used measurement to diagnose osteoporosis and predict fracture risk is
based on assessment of BMD by dual-energy X-ray absorptiometry (DXA). (NIH)
Measurements of BMD made at the hip predict hip fracture better than measurements made at
other sites while BMD measurement at the spine predicts spine fracture better than measures at
other sites. (NIH)
Pharmacologic therapy should be initiated to reduce fracture risk in women with:
• BMD T-scores below -2.0 by central dual x-ray absorptiometry (DXA) with no risk factors
• BMD T-scores below -1.5 by central dual x-ray absorptiometry (DXA) with one or more risk
factors
• A prior vertebral or hip fracture (NQF)

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Measure #41: Osteoporosis: Pharmacologic Therapy
DESCRIPTION:
Percentage of patients aged 50 years and older with a diagnosis of osteoporosis who were
prescribed pharmacologic therapy within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. Patients with a diagnosis of osteoporosis should be prescribed pharmacologic
therapy to treat osteoporosis. It is anticipated that clinicians who provide services for patients with
the diagnosis of osteoporosis will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed pharmacologic therapy within 12 months
Definitions:
• Pharmacologic Therapy: U.S. Food and Drug Administration approved pharmacologic
options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis
include, in alphabetical order: bisphosphonates (alendronate, ibandronate, and
risedronate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modules or
SERMs (raloxifene).
• "Prescribed" includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
Numerator Coding:
Pharmacologic Therapy Prescribed
CPT II 4005F: Pharmacologic therapy (other than minerals/vitamins) for osteoporosis
prescribed
OR

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OR

Pharmacologic Therapy not Prescribed for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4005F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing pharmacologic therapy for
osteoporosis
• 2P: Documentation of patient reason(s) for not prescribing pharmacologic therapy for
osteoporosis
• 3P: Documentation of system reason for not prescribing pharmacologic therapy for
osteoporosis
Pharmacologic Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4005F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Pharmacologic therapy for osteoporosis was not prescribed, reason not otherwise
specified

DENOMINATOR:
All patients aged 50 years and older with the diagnosis of osteoporosis
Denominator Coding:
An ICD-9 diagnosis code for osteoporosis and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 733.00, 733.01, 733.02, 733.03, 733.09
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Pharmacologic therapy is an evidence-based recommendation for the treatment of osteoporosis.
CLINICAL RECOMMENDATION STATEMENTS:
Agents approved by the FDA for osteoporosis prevention and/or treatment include (in alphabetical
order) bisphosphonates (alendronate, ibandronate, risedronate), salmon calcitonin, estrogen,
raloxifene, and teriparatide. All act by reducing bone resorption, except for teriparatide, which has
anabolic effects on bone. Although estrogen is not approved for treatment of osteoporosis, there is
level 1 evidence for its efficacy in reducing vertebral fractures, nonvertebral fractures, and hip
fractures. Level 1 evidence of efficacy in reducing the risk of vertebral fractures is available for all
the agents approved for treatment of osteoporosis (bisphosphonates, calcitonin, raloxifene, and
teriparatide). Prospective trials have demonstrated the effectiveness of bisphosphonates and
teriparatide in reducing the risk of nonvertebral fractures (level 1), but only bisphosphonates have
been shown to reduce the risk of hip fractures in prospective controlled trials (level 1). (AACE)
US Food and Drug Administration-approved pharmacologic options for osteoporosis prevention
and/or treatment of postmenopausal osteoporosis include, in alphabetical order: bisphosphonates
(alendronate, alendronate plus D, ibandronate, and risedronate, risedronate with 500 mg of

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calcium as the carbonate), calcitonin, estrogens (estrogens and/or hormone therapy), parathyroid
hormone [PTH (1-34), teriparatide], and selective estrogen receptor modulators or SERMS
(raloxifene). (NQF)

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Measure #43: Use of Internal Mammary Artery (IMA) in Coronary Artery Bypass Graft
(CABG) Surgery
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass graft
(CABG) surgery using an internal mammary artery (IMA)
INSTRUCTIONS:
This measure is to be reported for patients who undergo an isolated coronary artery bypass graft
(CABG) procedure during the reporting period. It is anticipated that clinicians who provide services
for isolated CABG will submit this measure. This measure is intended to reflect the quality of the
surgical services provided for isolated CABG patients. Isolated CABG refers to CABG using arterial
and/or venous grafts only. Part B claims data will be analyzed to determine “isolated” CABG. This
measure does not include patients undergoing repeat CABG surgery.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT procedure codes and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patient who received an IMA coronary artery bypass graft
Numerator Coding:
IMA Graft Performed
CPT II 4110F: Internal mammary artery graft performed for primary, isolated coronary
artery bypass graft procedure
OR

OR

IMA Graft not Performed for Medical Reasons
Append a modifier (1P) to the CPT Category II code 4110F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing an internal mammary
artery graft for primary, isolated coronary artery bypass graft procedure
IMA Graft not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4110F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Internal mammary artery graft not performed for primary, isolated coronary artery
bypass graft procedure, reason not otherwise specified

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DENOMINATOR:
Patients with isolated coronary artery bypass graft
Denominator Coding:
A CPT procedure code for isolated coronary artery bypass graft surgery is required to
identify patients for denominator inclusion.
CPT procedure codes: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518,
33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
RATIONALE:
A major innovation has been the introduction of off-bypass CABG, which has reduced the postprocedure length of stay in some centers to between 2 and 3 days. In some centers, this has led to
a total 3-month cost for single-vessel coronary bypass that is not significantly different from the
total 3-month cost for angioplasty of single-vessel disease. Considering the favorable long-term
patency of an internal mammary artery (IMA) graft to the LAD, the cost reductions possible with offbypass CABG may improve the relative cost-effectiveness of coronary bypass compared with
either medical therapy or percutaneous techniques, particularly for symptomatic, proximal LAD
disease.
CLINICAL RECOMMENDATION STATEMENTS:
Class I
In every patient undergoing CABG, the left internal mammary artery (IMA) should be given primary
consideration for revascularization of the left anterior descending (LAD) artery. (Level of Evidence:
B)

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Measure #44: Preoperative Beta-blocker in Patients with Isolated Coronary Artery Bypass
Graft (CABG) Surgery
DESCRIPTION:
Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass
(CABG) surgery who received a beta-blocker pre-operatively
INSTRUCTIONS:
This measure is to be reported for patients who undergo an isolated coronary artery bypass graft
(CABG) procedure during the reporting period. It is anticipated that clinicians who provide services
for isolated CABG will submit this measure. Isolated CABG refers to CABG using arterial and/or
venous grafts only. Isolated CABG refers CABG using arterial and/or venous grafts only. Part B
claims data will be analyzed to determine “isolated” CABG. The timeframe for this measure
includes the entire 24 hour period before the incision time.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT procedure codes and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients undergoing CABG with documented pre-operative beta-blocker

OR

Numerator Coding:
Pre-operative Beta-blocker Received
CPT II 4115F: Beta blocker administered within 24 hours prior to surgical incision
Pre-operative Beta-blocker not Received for Medical Reasons
Append a modifier (1P) to the CPT Category II code 4115F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not administering beta blocker within 24
hours prior to surgical incision

OR

Pre-operative Beta-blocker not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4115F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Beta blocker not administered within 24 hours prior to surgical incision, reason not
otherwise specified

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DENOMINATOR:
Patients with isolated coronary artery bypass graft
Denominator Coding:
A CPT procedure code for isolated coronary artery bypass graft surgery is required to
identify patients for denominator inclusion.
CPT procedure codes: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518,
33519, 33521, 33522, 33523, 33533, 33534, 33535, 33536
RATIONALE:
In patients at risk of cardiovascular complications in a variety of medical conditions, beta-blockers
have shown to reduce that risk. Studies show that patients with a history of myocardial infarction,
who have had beta-blocker therapy initiated and continued, have a 20 to 30% reduction in
subsequent coronary events, cardiovascular mortality, and all-cause mortality (Yusuf, 1985). In a
meta analysis by McGory et al (2005), long-term cardiac mortality and myocardial ischemia were
reduced significantly by perioperative beta blockade. Patients maintained on beta-blockers, without
complications that might warrant discontinuation, are good candidates for continuation of betablockers through the perioperative period.
CLINICAL RECOMMENDATION STATEMENTS:
Prevention of Postoperative Arrhythmias
Class I
Preoperative or early postoperative administration of beta-blockers in patients without
contraindications should be used as the standard therapy to reduce the incidence and/or clinical
sequelae of atrial fibrillation after CABG. (Level of Evidence: B)
The use of b-blockers, calcium channel blockers, and nitrates plays a significant role in ensuring
that the myocardial oxygen demand does not exceed the supply. Patients well compensated while
receiving these agents should be continued on their therapy through the perioperative period.
Special attention should be paid to avoiding excess catecholamine effects by the sudden
withdrawal of b-blocker therapy. At least one study supports the use of b-blocker immediately prior
to surgery: in 1988, Stone and colleagues gave oral b-blockers 2 hours prior to surgery and
reported a decrease in frequency of ST segment depression from 28% among control patients to
2% in treated patients. Similarly, in 1987, Pasternack and colleagues reported a reduction from
18% to 3% incidence of acute perioperative myocardial infarction in patients treated with
metoprolol immediately prior to and following surgery. More recently, Podesser and colleagues
demonstrated in patients undergoing coronary artery bypass procedures that the combination of
nifedipine and metoprolol was associated with a lower incidence of ischemic events than nifedipine
alone.

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Measure #45: Perioperative Care: Discontinuation of Prophylactic Antibiotics (Cardiac
Procedures)
DESCRIPTION:
Percentage of cardiac surgical patients aged 18 years and older undergoing procedures with the
indications for prophylactic antibiotics AND who received a prophylactic antibiotic, who have an
order for discontinuation of prophylactic antibiotics within 48 hours of surgical end time
INSTRUCTIONS:
This measure is to be reported each time a procedure is performed during the reporting period for
patients who undergo cardiac procedures with the indications for prophylactic antibiotics. There is
no diagnosis associated with this measure. It is anticipated that clinicians who perform the listed
surgical procedures as specified in the denominator coding will submit this measure.
This measure is reported using CPT Category II codes:
CPT procedure codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure. If multiple surgical procedures were performed on the same date of
service and submitted on the same claim form, it is not necessary to submit the CPT Category II
code with each procedure.
When reporting the measure, submit the listed CPT procedure code and the appropriate CPT
Category II code(s) OR the CPT Category II code(s) with the modifier. The modifiers allowed for
this measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Cardiac surgical patients who have an order for discontinuation of prophylactic antibiotics within 48
hours of surgical end time
Numerator Instructions: There must be documentation of order (written order, verbal
order, or standing order/protocol) specifying that prophylactic antibiotic is to be
discontinued within 48 hours of surgical end time OR specifying a course of antibiotic
administration limited to that 48-hour period (e.g., “to be given every 8 hours for three
doses”) OR documentation that prophylactic antibiotic was discontinued within 48 hours of
surgical end time.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Documentation of order for discontinuation of prophylactic antibiotics (written
order, verbal order, or standing order/protocol) within 48 hours of surgical end time
(Two CPT II codes [4043F & 4046F] are required on the claim form to submit this
category)

OR

CPT II 4043F: Documentation that an order was given to discontinue prophylactic
antibiotics within 48 hours of surgical end time, cardiac procedures
Note: CPT Category II codes 4043F may be provided for documentation that
antibiotic discontinuation within 48 hours was ordered or that antibiotic
discontinuation was accomplished.
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
Prophylactic Antibiotics not Discontinued for Medical Reasons
(Two CPT II codes [4043F-1P & 4046F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II code 4043F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4043F with 1P: Documentation of medical reason(s) for not discontinuing prophylactic
antibiotics within 48 hours of surgical end time, cardiac procedures
AND
CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
OR
If patient is not eligible for this measure because patient was not documented to
have prophylactic antibiotics given within 4 hours prior to surgical incision, report:
(One CPT II code [4042F] is required on the claim form to submit this category)

OR

CPT II 4042F: Documentation that prophylactic antibiotics were neither given within 4
hours prior to surgical incision nor given intraoperatively
Prophylactic Antibiotics not Discontinued, Reason not Specified
(Two CPT II codes [4043F-8P & 4046F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4043F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4043F with 8P: Order was not given to discontinue prophylactic antibiotics within 48
hours of surgical end time, cardiac procedures, reason not otherwise specified
AND

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CPT II 4046F: Documentation that prophylactic antibiotics were given within 4 hours prior
to surgical incision or given intraoperatively
DENOMINATOR:
All cardiac surgical patients aged 18 years and older undergoing procedures with the indications
for prophylactic antibiotics AND who received a prophylactic antibiotic
Denominator Instructions: For the purpose of this measure of antibiotic discontinuation,
patients may be counted as having “received a prophylactic antibiotic” if the antibiotic was
received within 4 hours prior to the surgical incision (or start of procedure when no incision
is required) or intraoperatively.
Denominator Coding:
A CPT procedure code for cardiac surgical procedures for which prophylactic antibiotics
are indicated is required to identify patients for denominator inclusion.
CPT procedure codes (Cardiac surgical procedure codes for which prophylactic
antibiotics are indicated for denominator inclusion):
SURGICAL PROCEDURE
Cardiothoracic Surgery

CPT CODE
33120, 33130, 33140, 33141, 33202, 33250, 33251,
33256, 33261, 33305, 33315, 33321, 33322, 33332,
33335, 33400, 33401, 33403, 33404, 33405, 33406,
33410, 33411, 33413, 33416, 33422, 33425, 33426,
33427, 33430, 33460, 33463, 33464, 33465, 33475,
33496, 33510, 33511, 33512, 33513, 33514, 33516,
33517, 33518, 33519, 33521, 33522, 33523, 33530,
33533, 33534, 33535, 33536, 33542, 33545, 33548,
33572, 35211, 35241, 35271, 35820

RATIONALE:
There is no evidence there is added benefit of prolonged prophylactic antibiotic use. Prolonged use
may increase antibiotic resistant organisms.
CLINICAL RECOMMENDATION STATEMENTS:
At a minimum, antimicrobial coverage must be provided from the time of incision to closure of the
incision. For most procedures, the duration of antimicrobial prophylaxis should be 24 hours or less,
with the exception of cardiothoracic procedures (up to 72 hours’ duration) and ophthalmic
procedures (duration not clearly established). (ASHP)
There is evidence indicating that antibiotic prophylaxis of 48 hours duration is effective. There is
some evidence that single-dose prophylaxis or 24-hour prophylaxis may be as effective as 48-hour
prophylaxis, but additional studies are necessary before confirming the effectiveness of prophylaxis
lasting less than 48 hours. There is no evidence that prophylaxis administered for longer than 48
hours is more effective than a 48-hour regimen. Optimal practice: Antibiotic prophylaxis is not
continued for more than 48 hours postoperatively. (STS) (Class IIa, Level B)

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Measure #46: Medication Reconciliation
DESCRIPTION:
Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g.,
hospital, skilled nursing facility, or rehabilitation facility) and seen within 60 days following
discharge in the office by the physician providing on-going care who had a reconciliation of the
discharge medications with the current medication list in the medical record documented
INSTRUCTIONS:
This measure is to be reported at an office visit occurring within 60 days of each inpatient facility
discharge date during the reporting period. There is no diagnosis associated with this measure. If
multiple claims are submitted within 60 days of inpatient discharge, only one instance of reporting
will be counted. Part B claims data will be analyzed to determine the inpatient facility discharge
date. This measure is appropriate for use in the ambulatory setting only. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding. This measure is not to be
reported unless a patient has been discharged from an inpatient facility within 60 days prior to the
outpatient visit.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes and the appropriate CPT
Category II codes OR the CPT Category II codes with the modifier. The reporting modifier allowed
for this measure is: 8P- reasons not otherwise specified. There are no allowable performance
exclusions for this measure.
NUMERATOR:
Patients who had a reconciliation of the discharge medications with the current medication list in
the medical record documented
Definition: The medical record must indicate that the clinician is aware of the inpatient
facility discharge medications and will either keep the inpatient facility discharge
medications or change the inpatient facility discharge medications or the dosage of an
inpatient facility discharge medication.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Documentation of Reconciliation of Discharge Medication with Current Medication
List in the Medical Record
(Two CPT II codes [1111F & 1110F] are required on the claim form to submit this
category)

OR

OR

CPT II 1111F: Discharge medications reconciled with the current medication list in
outpatient medical record
AND
CPT II 1110F: Patient discharged from an inpatient facility (eg hospital, skilled nursing
facility, or rehabilitation facility) within the last 60 days
If patient is not eligible for this measure because patient was not discharged from
an inpatient facility within the last 60 days, do not report any CPT Category II codes.
There are no reporting requirements in this case.
Discharge Medication not Reconciled with Current Medication List in the Medical
Record, Reason Not Specified
(Two CPT II codes [1111F-8P & 1110F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 1111F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 1111F with 8P: Discharge medications were not reconciled with the current
medication list in outpatient medical record, reason not otherwise specified
AND
CPT II 1110F: Patient discharged from an inpatient facility (eg hospital, skilled nursing
facility, or rehabilitation facility) within the last 60 days

DENOMINATOR:
All patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled
nursing facility, or rehabilitation facility) and seen within 60 days following discharge in the office by
the physician providing on-going care
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Medications are often changed while a patient is hospitalized. Continuity between inpatient and ongoing care is essential.

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CLINICAL RECOMMENDATION STATEMENTS:
No trials of the effects of physician acknowledgment of medications post-discharge were found.
However, patients are likely to have their medications changed during a hospitalization. One
observational study showed that 1.5 new medications were initiated per patient during
hospitalization, and 28% of chronic medications were canceled by the time of hospital discharge.
Another observational study showed that at one week post-discharge, 72% of elderly patients were
taking incorrectly at least one medication started in the inpatient setting, and 32% of medications
were not being taken at all. One survey study faulted the quality of discharge communication as
contributing to early hospital readmission, although this study did not implicate medication
discontinuity as the cause. (ACOVE)
First, a medication list must be collected. It is important to know what medications the patient has
been taking or receiving prior to the outpatient visit in order to provide quality care. This applies
regardless of the setting from which the patient came — home, long-term care, assisted living, etc.
The medication list should include all medications (prescriptions, over-the-counter, herbals,
supplements, etc.) with dose, frequency, route, and reason for taking it. It is also important to verify
whether the patient is actually taking the medication as prescribed or instructed, as sometimes this
is not the case.
At the end of the outpatient visit, a clinician needs to verify three questions:
1. Based on what occurred in the visit, should any medication that the patient was taking or
receiving prior to the visit be discontinued or altered?
2. Based on what occurred in the visit, should any prior medication be suspended pending
consultation with the prescriber?
3. Have any new prescriptions been added today?
These questions should be reviewed by the physician who completed the procedure, or the
physician who evaluated and treated the patient.
• If the answer to all three questions is “no,” the process is complete.
• If the answer to any question is “yes,” the patient needs to receive clear instructions about
what to do — all changes, holds, and discontinuations of medications should be
specifically noted. Include any follow-up required, such as calling or making appointments
with other practitioners and a timeframe for doing so. (IHI)

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Measure #47: Advance Care Plan
DESCRIPTION:
Percentage of patients aged 65 years and older who have an advance care plan or surrogate
decision maker documented in the medical record or documentation in the medical record that an
advance care plan was discussed but the patient did not wish or was not able to name a surrogate
decision maker or provide an advance care plan in the medical record
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
This measure is appropriate for use in all healthcare settings (e.g., inpatient, nursing home,
ambulatory) except the emergency department. For each of these settings, there should be
documentation in the medical record(s) that advance care planning was discussed or documented.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes and the appropriate CPT
Category II codes OR the CPT Category II code(s) with the modifier. The reporting modifier
allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable
performance exclusions for this measure.
NUMERATOR:
Patients who have an advance care plan or surrogate decision maker documented in the medical
record or documentation in the medical record that an advance care plan was discussed but
patient did not wish or was not able to name a surrogate decision maker or provide an advance
care plan
Definition: For the purposes of this measure, “documentation that patient did not wish or
was not able to name a surrogate decision or provide an advance care plan” may also
include, as appropriate, the following:
• That the patient’s cultural and/or spiritual beliefs preclude a discussion of advance
care planning, as it would be viewed as harmful to the patient's beliefs and thus
harmful to the physician-patient relationship
Numerator Instruction: If patient’s cultural and/or spiritual beliefs preclude a discussion of
advance care planning, report 1124F.

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Numerator Coding:
Advance Care Planning Discussed and Documented
CPT II 1123F: Advance Care Planning discussed and documented; advance care plan or
surrogate decision maker documented in the medical record
OR
CPT II 1124F: Advance Care Planning discussed and documented in the medical record;
patient did not wish or was not able to name a surrogate decision maker or provide an
advance care plan
OR

Advance Care Planning not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1123F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Advance care planning not documented, reason not otherwise specified

DENOMINATOR:
All patients aged 65 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99218, 99219, 99220, 99221, 99222, 99223, 99231, 99232, 99233, 99234, 99235,
99236, 99291*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326,
99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347,
99348, 99349, 99350
*Clinicians indicating the place of service as the emergency department will not be
included in this measure.
RATIONALE:
It is essential that the patient’s wishes regarding medical treatment be established as much as
possible prior to incapacity. The Work Group has determined that the measure should remain as
specified with no required time frame based on a review of the literature. Studies have shown that
people do change their preferences often with regard to advanced care planning, but it primarily
occurs after a major medical event or other health status change. In the stable patient, it would be
very difficult to define the correct interval. It was felt by the Work Group that the error rate in simply
not having addressed the issue at all is so much more substantial (Teno 1997) than the risk that an
established plan has become outdated that we should not define a specific time frame at this time.
As this measure is tested and reviewed, we will continue to evaluate if and when a specific time
frame should be included.
CLINICAL RECOMMENDATION STATEMENTS:
Advance directives are designed to respect patient’s autonomy and determine his/her wishes about
future life-sustaining medical treatment if unable to indicate wishes. Key interventions and
treatment decisions to include in advance directives are: resuscitation procedures, mechanical
respiration, chemotherapy, radiation therapy, dialysis, simple diagnostic tests, pain control, blood
products, transfusions, and intentional deep sedation.

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Oral statements
• Conversations with relatives, friends, and clinicians are most common form; should be
thoroughly documented in medical record for later reference.
• Properly verified oral statements carry same ethical and legal weight as those recorded in
writing.
Instructional advance directives (DNR orders, living wills)
• Written instructions regarding the initiation, continuation, withholding, or withdrawal of
particular forms of life-sustaining medical treatment.
• May be revoked or altered at any time by the patient.
• Clinicians who comply with such directives are provided legal immunity for such actions.
Durable power of attorney for health care or health care proxy
• A written document that enables a capable person to appoint someone else to make future
medical treatment choices for him or her in the event of decisional incapacity. (AGS)
The National Hospice and Palliative Care Organization provides the Caring Connection web site,
which provides resources and information on end-of-life care, including a national repository of
state-by-state advance directives.

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Measure #48: Assessment of Presence or Absence of Urinary Incontinence in Women
Aged 65 Years and Older
DESCRIPTION:
Percentage of female patients aged 65 years and older who were assessed for the presence or
absence of urinary incontinence within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is appropriate for use in the ambulatory setting only and is
considered a general screening measure. There is no diagnosis associated with this measure. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were assessed for the presence or absence of urinary incontinence within 12 months
Definition: Urinary incontinence is defined as any involuntary leakage of urine.
Numerator Coding:
Presence or Absence of Urinary Incontinence Assessed
CPT II 1090F: Presence or absence of urinary incontinence assessed
OR

OR

Presence or Absence of Urinary Incontinence not Assessed for Medical Reasons
Append a modifier (1P) to CPT Category II code 1090F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not assessing for the presence or
absence of urinary incontinence
Presence or Absence of Urinary Incontinence not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1090F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Presence or absence of urinary incontinence not assessed, reason not otherwise
specified

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DENOMINATOR:
All female patients aged 65 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Female patients may not volunteer information regarding incontinence so they should be asked by
their physician.
CLINICAL RECOMMENDATION STATEMENTS:
Strategies to increase recognition and reporting of UI are required and especially the perception
that it is an inevitable consequence of aging for which little or nothing can be done. (ICI)
Patients with urinary incontinence should undergo a basic evaluation that includes a history,
physical examination, measurement of post-void residual volume, and urinalysis. (ACOG) (Level C)
Health care providers should be able to initiate evaluation and treatment of UI basing their
judgment on the results of history, physical examination, post-voiding residual and urinalysis. (ICI)
(Grade B for women)

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Measure #49: Characterization of Urinary Incontinence in Women Aged 65 Years and
Older
DESCRIPTION:
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence
whose urinary incontinence was characterized at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated
that clinicians who provide services for patients with the diagnosis of urinary incontinence will
submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients whose urinary incontinence was characterized (may include one or more of the following:
frequency, volume, timing, type of symptoms and how bothersome to the patient) at least once
within 12 months

OR

Numerator Coding:
Urinary Incontinence Characterized
CPT II 1091F: Urinary incontinence characterized (eg frequency, volume, timing, type of
symptoms, how bothersome)
Urinary Incontinence not Characterized, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1091F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Urinary incontinence not characterized (eg frequency, volume, timing, type of
symptoms, how bothersome), reason not otherwise specified

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DENOMINATOR:
All female patients aged 65 years and older with a diagnosis of urinary incontinence
Denominator Coding:
An ICD-9 diagnosis code for urinary incontinence and a CPT E/M service code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.33, 788.34, 788.35, 788.36,
788.37, 788.38, 788.39
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Treatment indications are dependent on the severity and impact on the patient.
CLINICAL RECOMMENDATION STATEMENTS:
Patients with urinary incontinence should undergo a basic evaluation that includes a history,
physical examination, measurement of post-void residual volume, and urinalysis. (ACOG) (Level C)
Health care providers should be able to initiate evaluation and treatment of UI basing their
judgment on the results of history, physical examination, post-voiding residual and urinalysis. (ICI)
(Grade B for women)
Bladder diaries provide valuable information on severity and bladder capacity in older persons
without disability in the community. (ICI) (Grade B)

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Measure #50: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
DESCRIPTION:
Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence
with a documented plan of care for urinary incontinence at least once within 12 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is appropriate for use in the ambulatory setting only. It is anticipated
that clinicians who provide services for patients with the diagnosis of urinary incontinence will
submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients with a documented plan of care for urinary incontinence at least once within 12 months
Definition: Plan of care may include behavioral interventions (e.g., bladder training, pelvic
floor muscle training, prompted voiding), referral to specialist, surgical treatment, reassess
at follow-up visit, lifestyle interventions, addressing co-morbid factors, modification or
discontinuation of medications contributing to urinary incontinence, or pharmacologic
therapy.

OR

Numerator Coding:
Plan of Care for Urinary Incontinence Documented
CPT II 0509F: Urinary incontinence plan of care documented
Plan of Care for Urinary Incontinence not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 0509F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Urinary incontinence plan of care not documented, reason not otherwise specified

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DENOMINATOR:
All female patients aged 65 years and older with a diagnosis of urinary incontinence
Denominator Coding:
An ICD-9 diagnosis code for urinary incontinence and a CPT E/M service code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 307.6, 625.6, 788.30, 788.31, 788.33, 788.34, 788.35, 788.36,
788.37, 788.38, 788.39
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
A treatment option should be documented for the patient with incontinence.
CLINICAL RECOMMENDATION STATEMENTS:
All conservative management options used in younger adults can be used in selected frail, older,
motivated people. This includes:
• Bladder retraining
• Pelvic muscle exercises including biofeedback and/or electro-stimulation (ICI) (Grade B)
Pharmacologic agents, especially oxybutynin and tolterodine, may have a small beneficial effect on
improving symptoms of detrusor overactivity in women. (ACOG) (Level A)
Oxybutynin and potentially other bladder relaxants can improve the effectiveness of behavioral
therapies in frail older persons. (ICI) (Grade B)

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Measure #51: Chronic Obstructive Pulmonary Disease (COPD): Spirometry Evaluation
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of COPD who had spirometry
evaluation results documented
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period using the most recent
spirometry results in the patient record for patients seen during the reporting period. Do not limit
the search for spirometry results to the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis code, CPT E/M service codes, and
the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients with documented spirometry results in the medical record (FEV1 and FEV1/FVC)
Numerator Instructions: Look for most recent documentation of spirometry evaluation
results in the medical record; do not limit the search to the reporting period.

OR

OR

Numerator Coding:
Spirometry Results Documented
CPT II 3023F: Spirometry results documented and reviewed
Spirometry Results not Documented for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 3023F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not documenting and reviewing spirometry
results
• 2P: Documentation of patient reason(s) for not documenting and reviewing spirometry
results
• 3P: Documentation of system reason(s) for not documenting and reviewing spirometry
results

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Spirometry Results not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3023F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Spirometry results not documented and reviewed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 and older with a diagnosis of COPD
Denominator Coding:
An ICD-9 diagnosis code for COPD and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 491.0, 491.1, 491.20, 491.21, 491.22, 491.8, 491.9, 492.0,
492.8, 496
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Evaluation of lung function for a patient with COPD is vital to determine what treatments are
needed and whether those treatments are effective.
CLINICAL RECOMMENDATION STATEMENTS:
Spirometry should be performed in all patients suspected of COPD. This is necessary for
diagnosis, assessment of severity of the disease and for following the progress of the disease.
(ATS and ERS)
For the diagnosis and assessment of COPD, spirometry is the gold standard as it is the most
reproducible, standardized, and objective way of measuring airflow limitation. FEV1/FVC < 70%
and a postbronchodilator FEV1 < 80% predicted confirms the presence of airflow limitation that is
not fully reversible. (NHLBI/WHO)
A patient's decline in lung function is best tracked by periodic spirometry measurements. Useful
information about lung function decline is unlikely from spirometry measurements performed more
than once a year. Spirometry should be performed if there is a substantial increase in symptoms or
a complication. (NHLBI/WHO)

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Measure #52: Chronic Obstructive Pulmonary Disease (COPD): Bronchodilator Therapy
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of COPD and who have an
FEV1/FVC less than 70% and have symptoms who were prescribed an inhaled bronchodilator
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all COPD patients seen
during the reporting period. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed an inhaled bronchodilator
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Patient Prescribed Inhaled Bronchodilator Therapy
(Two CPT II codes [4025F & 3025F] are required on the claim form to submit this
category)

OR

CPT II 4025F: Inhaled bronchodilator prescribed
AND
CPT II 3025F: Spirometry test results demonstrate FEV1/FVC < 70% with COPD
symptoms (eg, dyspnea, cough/sputum, wheezing)

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Patient not Documented to have Inhaled Bronchodilator Prescribed for Medical,
Patient, or System Reasons
(Two CPT II codes [4025F-xP & 3025F] are required on the claim form to submit this
category)
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4025F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4025F with 1P: Documentation of medical reason(s) for not prescribing an inhaled
bronchodilator
• 4025F with 2P: Documentation of patient reason(s) for not prescribing an inhaled
bronchodilator
• 4025F with 3P: Documentation of system reason(s) for not prescribing an inhaled
bronchodilator
AND
CPT II 3025F: Spirometry test results demonstrate FEV1/FVC < 70% with COPD
symptoms (eg, dyspnea, cough/sputum, wheezing)
OR
If patient is not eligible for this measure because spirometry results demonstrate
FEV1/FVC ≥ 70% or patient does not have COPD symptoms, report:
Spirometry Results Demonstrate FEV1/FVC ≥ 70% or Patient Does not Have COPD
Symptoms
(One CPT II code [3027F] is required on the claim form to submit this category)
CPT II 3027F: Spirometry test results demonstrate FEV1/FVC ≥ 70% or patient does not
have COPD symptoms
OR
Spirometry Test not Performed or Documented
(One CPT II code [3025F-8P] is required on the claim form to submit this category)

OR

Append a reporting modifier (8P) to CPT Category II code 3025F to report circumstances
when the patient is not eligible for the measure.
• 3025F with 8P: Spirometry test not performed or documented
Patient not Documented to have Inhaled Bronchodilator Prescribed, Reason not
Specified
(Two CPT II codes [4025F-8P & 3025F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4025F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4025F with 8P: Inhaled bronchodilator not prescribed, reason not otherwise specified
AND

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CPT II 3025F: Spirometry test results demonstrate FEV1/FVC < 70% with COPD
symptoms (eg, dyspnea, cough/sputum, wheezing)
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of COPD, who have an FEV1/FVC <70 % and
have symptoms (e.g., dyspnea, cough/sputum, wheezing)
Denominator Coding:
An ICD-9 diagnosis code for COPD and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 491.0, 491.1, 491.20, 491.21, 491.22, 491.8, 491.9, 492.0,
492.8, 496
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Inhaled bronchodilator therapy is effective in treating and managing the symptoms of COPD,
particularly, for those patients with moderate to very severe COPD, and improving a patient’s
quality of life.
CLINICAL RECOMMENDATION STATEMENTS:
Short-acting bronchodilators can increase exercise tolerance acutely in COPD. (ATS and ERS)
Bronchodilator medications are central to the symptomatic management of COPD. (Evidence A)
(NHLBI/ WHO)
A combination of a short-acting β2-agonist and an anticholinergic produces greater and more
sustained improvements in FEV1 than either alone and does not produce evidence of tachyphylaxis
over 90 days of treatment. (Evidence A) (NHLBI/WHO)
In patients with Stage II: Moderate COPD to Stage IV: Very Severe COPD whose symptoms are
not adequately controlled with as-needed short-acting bronchodilators, adding regular treatment
with a long-acting inhaled bronchodilator is recommended. (Evidence A) NHLBI/WHO)
Regular treatment with long-acting bronchodilators is more effective and convenient than treatment
with short-acting bronchodilators, but more expensive. (Evidence A) (NHLBI/WHO)

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Measure #53: Asthma: Pharmacologic Therapy
DESCRIPTION:
Percentage of patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe
persistent asthma who were prescribed either the preferred long-term control medication (inhaled
corticosteroid) or an acceptable alternative treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all asthma patients seen
during the reporting period. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 2P- patient reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who were prescribed either the preferred long-term control medication (inhaled
corticosteroid or inhaled corticosteroid with long-acting inhaled beta2-agonist) or an acceptable
alternative treatment (leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustainedreleased methylaxanthines)
Numerator Instructions: Documentation of persistent asthma must be present. One
method of identifying persistent asthma is at least daily use of short-acting bronchodilators.
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Preferred Long-Term Control Medication or Acceptable Alternative Treatment
Prescribed
(Two CPT II codes [4015F & 1038F] are required on the claim form to submit this
category)
CPT II 4015F: Persistent asthma, preferred long term control medication or acceptable
alternative treatment prescribed
AND
CPT II 1038F: Persistent asthma (mild, moderate or severe)
OR

Preferred Long-Term Control Medication or Acceptable Alternative Treatment not
Prescribed for Patient Reasons
(Two CPT II codes [4015F-2P & 1038F] are required on the claim form to submit this
category)
Append a modifier (2P) to CPT Category II code 4015F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4015F with 2P: Documentation of patient reason(s) for not prescribing either the
preferred long-term control medication (inhaled corticosteroid or inhaled corticosteroid
with long-acting inhaled beta2-agonist) or an acceptable alternative treatment
(leukotriene modifiers, cromolyn sodium, nedocromil sodium, or sustained-released
methylaxanthines)
AND
CPT II 1038F: Persistent asthma (mild, moderate or severe)
OR
If patient is not eligible for this measure because patient does not have persistent
asthma, report:
(One CPT II code [1039F] is required on the claim form to submit this category)

OR

CPT II 1039F: Intermittent asthma
Preferred Long-Term Control Medication or Acceptable Alternative Treatment not
Prescribed, Reason not Specified
(Two CPT II codes [4015F-8P & 1038F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4015F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4015F with 8P: Persistent asthma, preferred long term control medication or
acceptable alternative treatment not prescribed, reason not otherwise specified
AND
CPT II 1038F: Persistent asthma (mild, moderate or severe)

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DENOMINATOR:
All patients aged 5 through 40 years with a diagnosis of mild, moderate, or severe persistent
asthma
Denominator Coding:
An ICD-9 diagnosis code for asthma and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21,
493.22, 493.81, 493.82, 493.90, 493.91, 493.92
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Although current guidelines recommend inhaled corticosteroids as the preferred pharmacological
treatment for persistent asthma, other long-term control medications are acceptable alternatives.
Long Acting-inhaled Beta2 Agonists (LABA) are recommended in combination with Inhaled
Corticosteroids
CLINICAL RECOMMENDATION STATEMENTS:
A stepwise approach to therapy is recommended to maintain long-term control:
• Step 1: Mild Intermittent Asthma
• No daily medication needed
• Step 2: Mild Persistent Asthma
• Preferred treatment: Low-dose inhaled corticosteroids (ICS)
• Alternative treatment: Cromolyn, leukotriene modifier, nedocromil, OR sustained-release
theophylline
• Step 3: Moderate Persistent Asthma
• Preferred treatment: Low-medium dose ICS + long-acting inhaled beta2-agonists (LABA)
• Alternative treatment: Increase medium-dose ICS OR low-medium dose ICS and either
leukotriene modifier or theophylline (If needed, may increase ICS within medium-dose
range in either treatment)
• Step 4: Severe Persistent Asthma
• Preferred treatment: High-dose ICS + LABA AND, if needed, corticosteroid tablets or syrup
long-term
Studies comparing ICS to cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists
are limited, but available evidence shows that none of these long-term control medications appear
to be as effective as ICS in improving asthma outcomes.
For quick relief for all patients, a short-acting bronchodilator is recommended as needed for
symptoms. (NAEPP/NHLBI)

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Measure #54: Electrocardiogram Performed for Non-Traumatic Chest Pain
DESCRIPTION:
Percentage of patients aged 40 years and older with an emergency department discharge
diagnosis of non-traumatic chest pain who had a 12-lead electrocardiogram (ECG) performed
INSTRUCTIONS:
This measure is to be reported each time a patient has been discharged from the emergency
department with a discharge diagnosis of non-traumatic chest pain during the reporting period.
Claims data will be analyzed to determine the emergency department discharge. Patients who
were discharged from an emergency department with a diagnosis of non-traumatic chest pain
should have documentation in the medical record of having a 12-lead ECG performed. It is
anticipated that clinicians who provide care in the emergency department will submit this measure.
The Part B claim form place-of-service field must indicate that the encounter has taken place in the
emergency department.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who had a 12-lead ECG performed

OR

OR

Numerator Coding:
12-Lead ECG Performed
CPT II 3120F: 12-Lead ECG Performed
12-Lead ECG not Performed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3120F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing a 12-Lead ECG
• 2P: Documentation of patient reason(s) for not performing a 12-Lead ECG
12-Lead ECG not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3120F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: 12-Lead ECG not Performed, reason not otherwise specified

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DENOMINATOR:
All patients aged 40 years and older with an emergency department discharge diagnosis of nontraumatic chest pain
Denominator Coding:
An ICD-9 diagnosis code for non-traumatic chest pain and a CPT E/M service code are
required to identify patients for denominator inclusion. The Part B claim form place-ofservice field must indicate emergency department.
ICD-9 diagnosis codes: 413.0, 413.1, 413.9, 786.50, 786.51, 786.52, 786.59
AND
CPT E/M service codes: 99281, 99282, 99283, 99284, 99285, 99291
AND
Place of Service Indicator: 23
RATIONALE:
All patients in the age group for which CAD/ACS is part of the differential diagnosis, should have a
12-lead ECG performed.
CLINICAL RECOMMENDATION STATEMENTS:
A 12-lead ECG should be performed and shown to an experienced emergency physician within 10
minutes of ED arrival for all patients with chest discomfort (or anginal equivalent) or other
symptoms of STEMI. (ACC/AHA)(Class I, Level C)
If pain is severe or pressure or substernal or exertional or radiating to jaw, neck, shoulder or arm,
then the following are recommended:
• 12-lead ECG (Rule)
• IV access, supplemental oxygen, cardiac monitor, serum cardiac markers (e.g.,
CKMB), CXR, nitrates, management of ongoing pain, admit (ACEP)

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Measure #55: Electrocardiogram Performed for Syncope
DESCRIPTION:
Percentage of patients aged 60 years and older with an emergency department discharge
diagnosis of syncope who had a 12-lead ECG performed
INSTRUCTIONS:
This measure is to be reported each time a patient has been discharged from the emergency
department with a discharge diagnosis of syncope during the reporting period. Claims data will be
analyzed to determine the emergency department discharge. Patients who experienced syncope
should have documentation in the medical record of having a 12-lead ECG performed. It is
anticipated that clinicians who provide care in the emergency department will submit this measure.
The Part B claim form place-of-service field must indicate that the encounter has taken place in the
emergency department.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who had a 12-lead ECG performed
Numerator Coding:
12-Lead ECG Performed
CPT II 3120F: 12-Lead ECG Performed
OR

OR

12-Lead ECG not Performed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3120F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing a 12-Lead ECG
• 2P: Documentation of patient reason(s) for not performing a 12-Lead ECG
12-Lead ECG not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3120F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: 12-Lead ECG not Performed, reason not otherwise specified

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DENOMINATOR:
All patients aged 60 years and older with an emergency department discharge diagnosis of
syncope
Denominator Coding:
An ICD-9 diagnosis code for syncope and a CPT E/M service code are required to identify
patients for denominator inclusion. The Part B claim form place-of-service field must
indicate emergency department.
ICD-9 diagnosis codes: 780.2
AND
CPT E/M service codes: 99281, 99282, 99283, 99284, 99285, 99291
AND
Place of Service Indicator: 23
RATIONALE:
12-lead ECG can occasionally pick up potentially life-threatening conditions such as pre-excitation
syndromes, prolonged QT syndromes, or Brugada’s syndrome in otherwise healthy appearing
young adults. 12-lead ECG testing is performed inconsistently, even in high risk patients; the
largest study to date of 12-lead ECG testing variation in ED syncope visits using a 9 year national
sample illustrated that 12-lead ECG testing was documented in only 59% of ED syncope visits.
CLINICAL RECOMMENDATION STATEMENTS:
Obtain a standard 12-lead ECG in patients with syncope when history and physical examination do
not reveal a diagnosis. (ACEP) (Level A)
• A patient with normal 12-lead ECG has a low likelihood of dysrhythmias as a cause of
syncope.
• Abnormal 12-lead ECG has been associated as being the most important predictor of
serious outcomes and a multivariate predictor for arrhythmia or death within 1 year after
the syncopal episode.

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Measure #56: Vital Signs for Community-Acquired Bacterial Pneumonia
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with vital signs documented and reviewed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community acquired
bacterial pneumonia should have documentation in the medical record of having vital signs
recorded and reviewed. It is anticipated that clinicians who provide care in the emergency
department or office setting will submit this measure. Clinicians utilizing the critical care code must
indicate the emergency department place-of-service code in order to be counted in the measure’s
denominator.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients with vital signs (temperature, pulse, respiratory rate, and blood pressure) documented and
reviewed
Definition: Medical record may include one of the following: clinician documentation that
vital signs were reviewed, dictation by the clinician including vital signs, clinician initials in
the chart that vital signs were reviewed, or other indication that vital signs had been
acknowledged by the clinician

OR

Numerator Coding:
Vital Signs Documented and Reviewed
CPT II 2010F: Vital signs (temperature, pulse, respiratory rate, and blood pressure)
documented and reviewed

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Vital Signs not Documented and Reviewed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2010F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Vital signs (temperature, pulse, respiratory rate, and blood pressure) not
documented and reviewed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia
Denominator Coding:
An ICD-9 diagnosis code for community-acquired bacterial pneumonia and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39,
482.40, 482.41, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1,
483.8, 485, 486, 487.0
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99291*
* Clinicians utilizing the critical care code must indicate the emergency department placeof-service (23) on the Part B claim form in order to report this measure.
RATIONALE:
Each of the vital signs should be recorded in the emergency department. While vital signs may be
routinely recorded, there likely is a gap in care on acting on those values that warrant further
evaluation. Moreover, it is important for physicians to review the vital signs to ensure continuous
quality improvement and consistent patient care.
CLINICAL RECOMMENDATION STATEMENTS:
It is necessary to assess the severity of illness. This includes the radiographic findings (multilobar
pneumonia or pleural effusion) and physical findings (respiratory rate, systolic and diastolic blood
pressure, signs of dehydrations and mental status). (ATS) (Level II Evidence)

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Measure #57: Assessment of Oxygen Saturation for Community-Acquired Bacterial
Pneumonia
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with oxygen saturation documented and reviewed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community-acquired
bacterial pneumonia would have documentation in the medical record of having oxygen saturation
assessed. It is anticipated that clinicians who provide care in the emergency department or office
setting will submit this measure. Clinicians utilizing the critical care code must indicate the
emergency department place-of-service code in order to be counted in the measure’s denominator.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified. Clinicians utilizing the critical care code must
indicate the emergency department place-of-service code in order to be counted in the measure’s
denominator.
NUMERATOR:
Patients with oxygen saturation documented and reviewed
Definition: Medical record may include one of the following: clinician documentation that
oxygen saturation was reviewed, dictation by the clinician including oxygen saturation,
clinician initials in the chart that oxygen saturation was reviewed, or other indication that
oxygen saturation had been acknowledged by the clinician
Numerator Coding:
Oxygen Saturation Documented and Reviewed
CPT II 3028F: Oxygen saturation results documented and reviewed (includes assessment
through pulse oximetry or arterial blood gas measurement)
OR

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Oxygen Saturation not Documented and Reviewed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 3028F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not documenting and reviewing oxygen
saturation
• 2P: Documentation of patient reason(s) for not documenting and reviewing oxygen
saturation
• 3P: Documentation of system reason(s) for not documenting and reviewing oxygen
saturation
OR

Oxygen Saturation not Documented and Reviewed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3028F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Oxygen saturation results not documented and reviewed, reason not otherwise
specified

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia
Denominator Coding:
An ICD-9 diagnosis code for community-acquired bacterial pneumonia and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39,
482.40, 482.41, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1,
483.8, 485, 486, 487.0
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99291*
* Clinicians utilizing the critical care code must indicate the emergency department placeof-service (23) on the Part B claim form in order to report this measure.
RATIONALE:
The assessment of oxygenation helps to assess the severity of the illness.
CLINICAL RECOMMENDATION STATEMENTS:
It is necessary to assess the severity of illness. This includes the radiographic findings (multilobar
pneumonia or pleural effusion) and physical findings (respiratory rate, systolic and diastolic blood
pressure, signs of dehydrations and mental status). For those patients with chronic heart or lung
disease, the assessment of oxygenation by pulse oximetry will help identify the need for
hospitalization. (ATS) (Level II Evidence)

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Measure #58: Assessment of Mental Status for Community-Acquired Bacterial Pneumonia
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with mental status assessed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community acquired
bacterial pneumonia should have documentation in the medical record of having mental status
assessed. It is anticipated that clinicians who provide care in the emergency department or office
setting will submit this measure. Clinicians utilizing the critical care code must indicate the
emergency department place-of-service code in order to be counted in the measure’s denominator.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients for whom mental status was assessed
Definition: Medical record may include documentation by clinician that patient’s mental
status was noted (e.g., patient is oriented or disoriented).
Numerator Coding:
Mental Status Assessed
CPT II 2014F: Mental status assessed
OR

Mental Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Mental status not assessed, reason not otherwise specified

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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia
Denominator Coding:
An ICD-9 diagnosis code for community-acquired bacterial pneumonia and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39,
482.40, 482.41, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1,
483.8, 485, 486, 487.0
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99291*
* Clinicians utilizing the critical care code must indicate the emergency department placeof-service (23) on the Part B claim form in order to report this measure.
RATIONALE:
The assessment of mental status helps to assess the severity of the illness.
CLINICAL RECOMMENDATION STATEMENTS:
It is necessary to assess the severity of illness. This includes the radiographic findings (multilobar
pneumonia or pleural effusion) and physical findings (respiratory rate, systolic and diastolic blood
pressure, signs of dehydrations and mental status). (ATS) (Level II Evidence)

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Measure #59: Empiric Antibiotic for Community-Acquired Bacterial Pneumonia
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial
pneumonia with an appropriate empiric antibiotic prescribed
INSTRUCTIONS:
This measure is to be reported once for each occurrence of community-acquired bacterial
pneumonia during the reporting period. Each unique occurrence is defined as a 45-day period from
onset of community-acquired bacterial pneumonia. Claims data will be analyzed to determine
unique occurrences. All patients 18 years and older with a diagnosis of community acquired
bacterial pneumonia should have documentation in the medical record of having an appropriate
empiric antibiotic prescribed. It is anticipated that clinicians who provide care in the emergency
department or office setting will submit this measure. Clinicians utilizing the critical care code must
indicate the emergency department place-of-service code in order to be counted in the measure’s
denominator.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients with appropriate empiric antibiotic prescribed
Definitions:
• Appropriate empiric antibiotic for treatment of community-acquired bacterial
pneumonia (CAP) should include any medication from one of the following four drug
classes: Fluoroquinolones, Macrolides, Doxycycline, Beta Lactam with Macrolide or
Doxycycline (as defined by current ATS/IDSA guidelines).
• "Prescribed" includes patients who are currently receiving medication(s) that follow the
treatment plan recommended at an encounter during the reporting period, even if the
prescription for that medication was ordered prior to the encounter.
Numerator Coding:
Appropriate Empiric Antibiotic Prescribed
CPT II 4045F: Appropriate empiric antibiotic prescribed
OR

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Appropriate Empiric Antibiotic not Prescribed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4045F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing appropriate empiric
antibiotic
• 2P: Documentation of patient reason(s) for not prescribing appropriate empiric
antibiotic
• 3P: Documentation of system reason(s) for not prescribing appropriate empiric
antibiotic
OR

Appropriate Empiric Antibiotic not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4045F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Appropriate empiric antibiotic not prescribed, reason not otherwise specified

DENOMINATOR:
All patients aged 18 years and older with the diagnosis of community-acquired bacterial pneumonia
Denominator Coding:
An ICD-9 diagnosis code for community-acquired bacterial pneumonia and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 481, 482.0, 482.1, 482.2, 482.30, 482.31, 482.32, 482.39,
482.40, 482.41, 482.49, 482.81, 482.82, 482.83, 482.84, 482.89, 482.9, 483.0, 483.1,
483.8, 485, 486, 487.0
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99281, 99282, 99283, 99284, 99285, 99291*
* Clinicians utilizing the critical care code must indicate the emergency department placeof-service (23) on the Part B claim form in order to report this measure.
RATIONALE:
All patients need to be treated empirically according to the guideline recommendations.
CLINICAL RECOMMENDATION STATEMENTS:
All patients should be treated empirically. Patients treated as outpatients with no cardiopulmonary
disease and no modifying factors should be treated with advanced generation macrolide:
azithromycin or clarithromycin or doxycycline. Patients treated as an outpatient with
cardiopulmonary disease and/or risk factors should be treated with beta lactam plus macrolide or
doxycycline or fluoroquinolone alone. Empiric therapy based on the ATS guidelines lead to better
outcomes than if the guidelines are not followed. (ATS) (Level II Evidence)

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Fluoroquinolones (gatifloxacin, gemifloxacin, levofloxacin, and moxifloxacin) are recommended for
initial empiric therapy of selected outpatients with CAP. (Level A Recommendation, Level I
Evidence)
Other options (macrolides and doxycycline) are generally preferred for uncomplicated infections in
outpatients. (IDSA) (Level A Recommendation, Level I Evidence)
A macrolide is recommended as monotherapy for selected outpatients, such as those who were
previously well and not recently treated with antibiotics. (Level A Recommendation, Level l
Evidence)
A macrolide plus a beta lactam is recommended for initial empiric treatment of outpatients in whom
resistance is an issue. (IDSA) (Level A Recommendation, Level I Evidence)

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Measure #64: Asthma Assessment
DESCRIPTION:
Percentage of patients aged 5 through 40 years with a diagnosis of asthma who were evaluated
during at least one office visit within 12 months for the frequency (numeric) of daytime and
nocturnal asthma symptoms
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with asthma
seen during the reporting period. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients who were evaluated during at least one office visit within 12 months for the frequency
(numeric) of daytime and nocturnal asthma symptoms
Numerator Instructions: To be counted in calculation of this measure, symptom
frequency must be numerically quantified. Measure may also be met by clinician
documentation or patient completion of an asthma assessment tool/survey/questionnaire.
Assessment tool may include the Quality Metric Asthma Control Test™, National Asthma
Education & Prevention Program (NAEPP) Asthma Symptoms, and Peak Flow Diary.

OR

Numerator Coding:
Asthma Symptom Frequency Evaluated
CPT II 1005F: Asthma symptoms evaluated (includes physician documentation of numeric
frequency of symptoms or patient completion of an asthma assessment
tool/survey/questionnaire)
Asthma Symptom Frequency not Evaluated, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1005F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Asthma symptoms not evaluated, reason not otherwise specified

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DENOMINATOR:
All patients aged 5 through 40 years with a diagnosis of asthma
Denominator Coding:
An ICD-9 diagnosis code for asthma and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 493.00, 493.01, 493.02, 493.10, 493.11, 493.12, 493.20, 493.21,
493.22, 493.81, 493.82, 493.90, 493.91, 493.92
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Appropriate treatment of asthma patients requires accurate classification of asthma severity.
Physician assessment of the frequency of asthma symptoms is the first step in classifying asthma
severity.
CLINICAL RECOMMENDATION STATEMENTS:
To determine whether the goals of therapy are being met, monitoring is recommended in the 6
areas listed below:
• Signs and symptoms (daytime; nocturnal awakening) of asthma
• Pulmonary function (spirometry; peak flow monitoring)
• Quality of life/functional status
• History of asthma exacerbations
• Pharmacotherapy (as-needed use of inhaled short-acting beta2-agonist, adherence to
regimen of long-term-control medications)
• Patient-provider communication and patient satisfaction (NAEPP/NHLBI)

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Measure #65: Appropriate Treatment for Children with Upper Respiratory Infection (URI)
DESCRIPTION:
Percentage of children aged 3 months through 18 years with a diagnosis of upper respiratory
infection (URI) who were not prescribed or dispensed an antibiotic prescription on or within 3 days
of the initial date of service
INSTRUCTIONS:
This measure is to be reported once for each occurrence of upper respiratory infection during the
reporting period. Claims data will be analyzed to determine unique occurrences. This measure may
be reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons.
NUMERATOR:
Patients who were not dispensed an antibiotic prescription on or within 3 days of the initial date of
service
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom antibiotics were neither prescribed nor dispensed over the number of
patients in the denominator (patients aged 3 months through 18 years with URI). A higher
score indicates appropriate treatment of patients with URI (e.g., the proportion for whom
antibiotics were not prescribed or dispensed).
Numerator Coding:
Antibiotic not Prescribed or Dispensed
CPT II 4124F: Antibiotic neither prescribed nor dispensed
OR

OR

Antibiotic Prescribed or Dispensed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4120F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for prescribing or dispensing antibiotic
Antibiotic Prescribed or Dispensed
CPT II 4120F: Antibiotic prescribed or dispensed

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DENOMINATOR:
All patients aged 3 months through 18 years with a diagnosis of upper respiratory infection
Denominator Coding:
An ICD-9 diagnosis code for upper respiratory infection (URI) and a CPT E/M service code
are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 460, 465.0, 465.8, 465.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Existing clinical guidelines do not support the use of antibiotics for the common cold/upper
respiratory infection.
CLINICAL RECOMMENDATION STATEMENTS:
Recent clinical practice guidelines set out the evidence supporting the recommendations for
treating a host of upper respiratory tract infections in pediatrics. The guidelines do not recommend
antibiotics for a majority of upper respiratory tract infections, except for conditions with bacterial
etiology such as acute otitis media, bacterial sinusitis, mucopurulent rhinitis with prolonged
symptoms, i.e., at least 10 days of continual symptoms, and group A streptococcal pharyngitis (but
only cases with a confirmatory test for group A strep). The guidelines support targeting treatment of
non-specific URI (the common cold) or viral rhinosinusitis with antibiotics as an indicator of
inappropriate antibiotic prescribing.

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Measure #66: Appropriate Testing for Children with Pharyngitis
DESCRIPTION:
Percentage of children aged 2 through 18 years with a diagnosis of pharyngitis, who were
prescribed an antibiotic and who received a group A streptococcus (strep) test for the episode
INSTRUCTIONS:
This measure is to be reported once for each occurrence of pharyngitis during the reporting period.
Claims data will be analyzed to determine unique occurrences. This measure is intended to reflect
the quality of services provided for the primary management of patients with pharyngitis who were
dispensed an antibiotic. This measure may be reported by clinicians who perform the quality
actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who were dispensed an antibiotic and who received a group A streptococcus (strep) test
for the episode
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Group A Streptococcus Test Performed and Antibiotic Prescribed
(Two CPT II codes [3210F & 4120F] are required on the claim form to submit this
category)

OR

CPT II 3210F: Group A Strep Test Performed
AND
CPT II 4120F: Antibiotic prescribed or dispensed

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Group A Streptococcus Test not Performed for Medical Reasons
(Two CPT II codes [3210F-1P & 4120F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II codes 3210F to report documented
circumstances that appropriately exclude patients from the denominator.
• 3210F with 1P: Documentation of medical reason(s) for not Performing Group A Strep
Test
AND
CPT II 4120F: Antibiotic prescribed or dispensed
OR
If patient is not eligible for this measure because patient was not prescribed
antibiotics, report:
(One CPT II code [4124F] is required on the claim form to submit this category)
CPT II 4124F: Antibiotic neither prescribed nor dispensed
OR

Group A Streptococcus Test not Performed, Reason not Specified
(Two CPT II codes [3210F-8P & 4120F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3210F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3210F with 8P: Group A Strep Test not Performed, reason not otherwise specified
AND
CPT II 4120F: Antibiotic prescribed or dispensed

DENOMINATOR:
All patients aged 2 through 18 years with a diagnosis of pharyngitis
Denominator Coding:
An ICD-9 diagnosis code for pharyngitis and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 034.0, 462, 463
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Clinical practice guidelines recommend group A streptococcus pharyngitis be treated with
antibiotics (Schwartz et al, 1998).

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CLINICAL RECOMMENDATION STATEMENTS:
The group A strep test (rapid assay or throat culture) is the definitive test of group A strep
pharyngitis. Pharyngitis is the only respiratory tract infection with an objective diagnostic test that
can be validated with administrative data, and not medical records. A process measure that
requires the performance of a group A strep test for children given antibiotics for pharyngitis is
supported by the guidelines. (Ibid)

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Measure #67: Myelodysplastic Syndrome (MDS) and Acute Leukemias: Baseline
Cytogenetic Testing Performed on Bone Marrow
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of MDS or an acute leukemia who
had baseline cytogenetic testing performed on bone marrow
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period, regardless of when the baseline testing is performed. It is anticipated that
clinicians who provide services for patients with the diagnosis of myelodysplastic syndromes or an
acute leukemia (not in remission) will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who had baseline cytogenetic testing performed on bone marrow
Definition: Baseline cytogenetic testing refers to testing that is performed at time of
diagnosis or prior to initiating treatment (transfusion, growth factors, or antineoplastic
therapy) for that diagnosis

OR

Numerator Coding:
Baseline Cytogenetic Testing Performed
CPT II 3155F: Cytogenetic testing performed on bone marrow at time of diagnosis or prior
to initiating treatment

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Baseline Cytogenetic Testing not Performed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 3155F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing baseline cytogenetic
testing on bone marrow (e.g., no liquid bone marrow or fibrotic marrow)
• 2P: Documentation of patient reason(s) for not performing baseline cytogenetic testing
on bone marrow (e.g., at time of diagnosis receiving palliative care or not receiving
treatment as defined above)
• 3P: Documentation of system reason(s) for not performing baseline cytogenetic testing
on bone marrow (e.g., patient previously treated by another physician at the time
cytogenetic testing performed)
OR

Baseline Cytogenetic Testing not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3155F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Cytogenetic testing not performed on bone marrow at time of diagnosis or prior to
initiating treatment, reason not otherwise specified

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of MDS or an acute leukemia
Denominator Coding:
An ICD-9 diagnosis code for Myelodysplastic Syndrome (MDS) or acute leukemias (not in
remission) and a CPT E/M service code are required to identify patients for denominator
inclusion.
ICD-9 diagnosis codes: 204.00, 205.00, 206.00, 207.00, 207.20, 208.00, 238.72, 238.73,
238.74, 238.75
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
For MDS:
Cytogenetic testing is an integral component in calculating the International Prognostic Scoring
System (IPSS) score. Cytogenetic testing should be performed on the bone marrow of patients
with MDS in order to guide treatment options, determine prognosis, and predict the likelihood of
disease evolution to leukemia.
For acute leukemias:
In addition to establishing the type of acute leukemia, cytogenetic testing is essential to detect
chromosomal abnormalities that have diagnostic, prognostic, and therapeutic significance.

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CLINICAL RECOMMENDATION STATEMENTS:
For MDS:
Bone marrow aspiration and biopsy are needed to calculate the degree of hematopoietic cell
maturation abnormalities and relative proportions, percentage of marrow blasts, marrow cellularity,
presence or absence of ringed sideroblasts (and presence of iron per se), and fibrosis. Marrow
cytogenetics should be obtained because they are of major importance for prognosis (Category 2A
Recommendation). (NCCN)
The decision to treat patients having marrow blasts in the range of 20% to 30% with intensive AML
therapy is thus complex and should be individualized. The clinician should consider such factors as
age, antecedent factors, cytogenetics, comorbidities, pace of disease, and performance status
(Category 2A Recommendation). (NCCN)
A chromosome abnormality confirms the presence of a clonal disorder aiding the distinction
between MDS and reactive causes of dysplasia, and in addition has major prognostic value.
Cytogenetic analysis should therefore be performed for all patients in whom a bone marrow
examination is indicated. (BCSH)
For acute leukemias:
The initial evaluation has two objectives. The first is to identify the pathology causing the disease
including factors such as prior toxic exposure or myelodysplasia, cytogenetics and molecular
markers that may have an impact on chemoresponsiveness and propensity for relapse which may
guide choice of treatment. The second objective focuses on patient-specific factors including
comorbid conditions that may affect an individual's ability to tolerate chemotherapy (Category 2A
Recommendation). (NCCN)
Although cytogenetic information is usually unknown when treatment is initiated in patients with de
novo AML, karyotype represents the single most important prognostic factor for predicting
remission rate, relapse, and overall survival. Therefore, the importance of obtaining sufficient
samples of marrow or peripheral blood blasts at diagnosis for this analysis cannot be
overemphasized (Category 2A Recommendation). (NCCN)

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Measure #68: Myelodysplastic Syndrome (MDS): Documentation of Iron Stores in
Patients Receiving Erythropoietin Therapy
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of MDS who are receiving
erythropoietin therapy with documentation of iron stores prior to initiating erythropoietin therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all MDS patients seen
during the reporting period, regardless of when the documentation of iron stores occurs. It is
anticipated that clinicians who provide services for patients with the diagnosis of myelodysplastic
syndromes will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 3P- system reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients with documentation of iron stores prior to initiating erythropoietin therapy
Definitions:
• Documentation of iron stores includes either: bone marrow examination including iron
stain OR serum iron measurement by ferritin or serum iron and TIBC
• For the purpose of this measure, erythropoietin therapy includes the following
medications: epoetin and darbepoetin
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Documentation of Iron Stores Prior to Initiating Erythropoietin Therapy Performed
(Two CPT II codes [3160F & 4090F] are required on the claim form to submit this
category)
CPT II 3160F: Documentation of iron stores prior to initiating erythropoietin therapy
AND
CPT II 4090F: Patient receiving erythropoietin therapy
OR

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Documentation of Iron Stores Prior to Initiating Erythropoietin Therapy not
Performed for System Reasons
(Two CPT II codes [3160F-3P & 4090F] are required on the claim form to submit this
category)
Append a modifier (3P) to CPT Category II code 3160F to report documented
circumstances that appropriately exclude patients from the denominator.
• 3160F with 3P: Documentation of system reason(s) for not documenting iron stores
prior to initiating erythropoietin therapy
AND
CPT II 4090F: Patient receiving erythropoietin therapy
OR
If patient is not eligible for this measure because patient is not receiving
erythropoietin therapy, report:
(One CPT II code [4095F] is required on the claim form to submit this category)
CPT II 4095F: Patient not receiving erythropoietin therapy
OR

Documentation of Iron Stores Prior to Initiating Erythropoietin Therapy not
Performed, Reason not Specified
(Two CPT II codes [3160F-8P & 4090F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3160F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3160F with 8P: Iron stores prior to initiating erythropoietin therapy not documented,
reason not otherwise specified
AND
CPT II 4090F: Patient receiving erythropoietin therapy

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of MDS who are receiving erythropoietin
therapy
Denominator Coding:
An ICD-9 diagnosis code for Myelodysplastic Syndrome (MDS) and a CPT E/M service
code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 238.72, 238.73, 238.74, 238.75
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
To be effective erythropoietin requires that adequate iron stores be present due to iron’s
importance in red-blood-cell synthesis. Iron deficiency presents a major limitation to the efficacy of
erythropoietin therapy.
CLINICAL RECOMMENDATION STATEMENTS:
Anemia related to MDS generally presents as a hypoproductive macrocytic anemia, often
associated with suboptimal elevation of serum Epo levels. Iron repletion needs to be verified before
instituting Epo therapy (Category 2A Recommendation). (NCCN)

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Measure #69: Multiple Myeloma: Treatment with Bisphosphonates
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of multiple myeloma, not in
remission, who were prescribed or received intravenous bisphosphonate therapy within the 12month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide services for the patients with the
diagnosis of multiple myeloma, not in remission, will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who were prescribed or received intravenous bisphosphonate therapy within the 12 month
reporting period
Definition: For the purpose of this measure bisphosphonate therapy includes the following
medications: pamidronate and zoledronate

OR

OR

Numerator Coding:
Intravenous Bisphosphonate Therapy Prescribed or Received
CPT II 4100F: Bisphosphonate therapy, intravenous, ordered or received
Intravenous Bisphosphonate Therapy not Prescribed or Received for Medical or
Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4100F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing bisphosphonates
• 2P: Documentation of patient reason(s) for not prescribing bisphosphonates

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Intravenous Bisphosphonate Therapy not Prescribed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4100F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Bisphosphonate therapy, intravenous, not ordered or received, reason not
otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of multiple myeloma, not in remission
Denominator Coding:
An ICD-9 diagnosis code for Multiple Myeloma (MM), not in remission, and a CPT E/M
service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis code: 203.00
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Multiple myeloma is a disease characterized by bone destruction, in the form of diffuse osteopenia
and/or osteolytic lesions, which develop in 85% of patients. Bisphosphonates can inhibit bone
resorption by reducing the number and activity of osteoclasts and therefore could “reduce pain and
bone fractures in people with multiple myeloma”.
CLINICAL RECOMMENDATION STATEMENTS:
Based on published data and clinical experience, the guidelines recommend the use of
bisphosphonates for all patients with multiple myeloma who have bone disease, including
osteopenia. In 10% to 20% of patients with earlier-stage disease who do not have bone disease,
bisphosphonates may be considered but preferably in a clinical trial (Category 1
Recommendation). (NCCN)
Intravenous bisphosphonates should be administered monthly for patients with MM and lytic
disease evident on plain radiographs (Grade A, Level II). It is reasonable to start intravenous
bisphosphonates in patients with MM who do not have lytic bone disease if there is evidence of
osteopenia or osteoporosis on bone mineral density studies (Consensus Recommendation, Level
N/A). No randomized clinical trials support the use of bisphosphonates in patients with smoldering
MM. We believe that bisphosphonates should be used only in the setting of a clinical trial [in these
patients] (Consensus Recommendation, Level N/A). (Mayo Clinic)

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Measure #70: Chronic Lymphocytic Leukemia (CLL): Baseline Flow Cytometry
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of CLL who had baseline flow
cytometry studies performed
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period, regardless of when the baseline flow cytometry studies are performed. It is
anticipated that clinicians who provide services for patients with the diagnosis of chronic
lymphocytic leukemia, not in remission, will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who had baseline flow cytometry studies performed
Definition: Baseline flow cytometry studies refer to testing that is performed at time of
diagnosis or prior to initiating treatment for that diagnosis. Treatment may include antineoplastic therapy.
Numerator Coding:
Baseline Flow Cytometry Studies Performed
CPT II 3170F: Flow cytometry studies performed at time of diagnosis or prior to initiating
treatment
OR

OR

Baseline Flow Cytometry Studies not Performed for Medical, Patient, or System
Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 3170F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing baseline flow cytometry
studies
• 2P: Documentation of patient reason(s) for not performing baseline flow cytometry
studies
• 3P: Documentation of system reason(s) for not performing baseline flow cytometry
studies

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Baseline Flow Cytometry Studies not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3170F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Flow cytometry studies not performed at time of diagnosis or prior to initiating
treatment, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of CLL
Denominator Coding:
An ICD-9 diagnosis code for chronic lymphocytic leukemia, not in remission, and a CPT
E/M service code are required to identify patients for denominator inclusion.
ICD-9 diagnosis code: 204.10
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Due to the distinct pattern of protein antigens expressed in CLL, flow cytometry should be
performed in order to confirm the diagnosis, correctly characterize the pathological cells, and
determine prognosis. In some instances, flow cytometry may also offer additional therapeutically
relevant information.
CLINICAL RECOMMENDATION STATEMENTS:
As with all the lymphoid neoplasms, adequate hematopathologic review is essential to establish an
accurate diagnosis of chronic lymphocytic leukemia and small lymphocytic lymphoma CLL/SLL.
…a combination of morphologic and flow cytometric studies may provide adequate information to
provide a diagnosis. This is particularly true for the diagnosis of CLL. Flow cytometric studies
performed on patients with leukemic cell burden include kappa/lambda to [assess] clonality…
Distinguishing CLL/SLL from mantle cell lymphoma is essential (Category 2A Recommendation).
(NCCN)

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Measure #71: Hormonal Therapy for Stage IC - III ER/PR Positive Breast Cancer
DESCRIPTION:
Percentage of female patients aged 18 years and older with Stage IC through IIIC, estrogen
receptor (ER) or progesterone receptor (PR) positive breast cancer who were prescribed tamoxifen
or aromatase inhibitor (AI) during the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all female patients with
breast cancer seen during the reporting period. It is anticipated that clinicians who treat female
patients with Stage IC through IIIC, estrogen receptor (ER) or progesterone receptor (PR) positive
breast cancer will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12 month reporting
period
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Tamoxifen or Aromatase Inhibitor Prescribed
(Three CPT II codes [4179F & 33xxF & 3315F] are required on the claim form to submit
this category)
Report 3305F for the Stage T1c Breast Cancer – Tumor more than 1 cm but not more than
2 cm in greatest dimension
CPT II 4179F: Tamoxifen or aromatase inhibitor (AI) prescribed
AND
CPT II 3305F: AJCC Cancer Stage IC, documented
OR
CPT II 3306F: AJCC Cancer Stage IIA, documented
OR

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CPT II 3307F: AJCC Cancer Stage IIB, documented
OR
CPT II 3309F: AJCC Cancer Stage IIIA, documented
OR
CPT II 3310F: AJCC Cancer Stage IIIB, documented
OR
CPT II 3311F: AJCC Cancer Stage IIIC, documented

OR

AND
CPT II 3315F: Estrogen receptor (ER) or progesterone receptor (PR) positive breast
cancer
Tamoxifen or Aromatase Inhibitor not Prescribed for Medical, Patient, or System
Reasons
(Three CPT II codes [4179F-xP & 33xxF & 3315F] are required on the claim form to submit
this category)
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4179F to report documented
circumstances that appropriately exclude patients from the denominator
• 4179F with 1P: Documentation of medical reason(s) for not prescribing tamoxifen or
aromatase inhibitor (eg, patient’s disease has progressed to metastatic; patient is
receiving a gonadotropin-releasing hormone analogue, patient has received
oophorectomy, patient is receiving radiation or chemotherapy, patient’s diagnosis date
was ≥ 5 years from reporting date)
• 4179F with 2P: Documentation of patient reason(s) for not prescribing tamoxifen or
aromatase inhibitor (eg, patient refusal)
• 4179F with 3P: Documentation of system reason(s) for not prescribing tamoxifen or
aromatase inhibitor (eg, patient is currently enrolled in a clinical trial)
AND
CPT II 3305F: AJCC Cancer Stage IC, documented
OR
CPT II 3306F: AJCC Cancer Stage IIA, documented
OR
CPT II 3307F: AJCC Cancer Stage IIB, documented
OR
CPT II 3309F: AJCC Cancer Stage IIIA, documented
OR
CPT II 3310F: AJCC Cancer Stage IIIB, documented
OR
CPT II 3311F: AJCC Cancer Stage IIIC, documented
AND
CPT II 3315F: Estrogen receptor (ER) or progesterone receptor (PR) positive breast
cancer

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OR
If patient is not eligible for this measure because patient is not stage IC through IIIC
breast cancer, report:
Patient not Stage IC through IIIC Breast Cancer
(One CPT II code [33xxF] is required on the claim form to submit this category)
Note: If reporting a code from the category below (3302F, 3303F, or 3312F), it is not
necessary to report the patient’s ER/PR status.
Report 3303F for the following Stage I Breast Cancers:
T1a - Tumor more than 0.1 cm but not more than 0.5 cm in greatest dimension
T1b - Tumor more than 0.5 cm but not more than 1 cm in greatest dimension
CPT II 3302F: AJCC Cancer Stage 0, documented
OR
CPT II 3303F: AJCC Cancer Stage IA, documented
OR
CPT II 3312F: AJCC Cancer Stage IV, documented
OR
If patient is not eligible for this measure because patient is estrogen receptor (ER)
and progesterone receptor (PR) negative, report:
Patient is Estrogen Receptor (ER) and Progesterone Receptor (PR) Negative
(One CPT II code [3316F] is required on the claim form to submit this category)
Note: If reporting code 3316F, it is not necessary to report the patient’s AJCC Cancer
Stage.
CPT II 3316F: Estrogen receptor (ER) and progesterone receptor (PR) negative breast
cancer
OR
If patient is not eligible for this measure because the cancer stage is not
documented OR the ER/PR is not documented, report:
Cancer Stage not Documented OR ER/PR not Documented
(One CPT II code [33xxF-8P] is required on the claim form to submit this category)

OR

Append a reporting modifier (8P) to one of the following CPT Category II codes to report
circumstances when the patient is not eligible for the measure.
• 3305F with 8P: No documentation of cancer stage
OR
• 3316F with 8P: No documentation of estrogen receptor (ER) and progesterone
receptor (PR) status

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Tamoxifen or Aromatase Inhibitor not Prescribed, Reason not Specified
(Three CPT II codes [4179F-8P & 33xxF & 3315F] are required on the claim form to submit
this category)
Append a reporting modifier (8P) to CPT Category II code 4179F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4179F with 8P: Tamoxifen or aromatase inhibitor not prescribed, reason not otherwise
specified
AND
CPT II 3305F: AJCC Cancer Stage IC, documented
OR
CPT II 3306F: AJCC Cancer Stage IIA, documented
OR
CPT II 3307F: AJCC Cancer Stage IIB, documented
OR
CPT II 3309F: AJCC Cancer Stage IIIA, documented
OR
CPT II 3310F: AJCC Cancer Stage IIIB, documented
OR
CPT II 3311F: AJCC Cancer Stage IIIC, documented
AND
CPT II 3315F: Estrogen receptor (ER) or progesterone receptor (PR) positive breast
cancer
DENOMINATOR:
All female patients aged 18 years and older with Stage IC through IIIC, estrogen receptor (ER) or
progesterone receptor (PR) positive breast cancer
Denominator Coding:
An ICD-9 diagnosis code for breast cancer and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Despite evidence suggesting the role of adjuvant endocrine therapy in lowering the risk of tumor
recurrence, many female patients who should be receiving this therapy are not. This measure
assesses whether patients with a certain stage of breast cancer (IC through IIIC) and ER/PR+ are
currently receiving the therapy. There are allowable medical, patient, and system reasons to
document instances in which a woman with stage IC through IIIC, ER/PR+ may not be a candidate
for the therapy. Note: the reporting/managing physician does not need to have actually written the

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prescription; however the reporting/managing physician must verify that the patient already has
been prescribed the hormonal therapy by another physician.
CLINICAL RECOMMENDATION STATEMENTS:
Adjuvant therapy for postmenopausal women with hormone receptor–positive breast cancer should
include an aromatase inhibitor in order to lower the risk of tumor recurrence. Aromatase inhibitors
are appropriate as initial treatment for women with contraindications to tamoxifen. For all other
postmenopausal women, treatment options include 5 years of aromatase inhibitors treatment or
sequential therapy consisting of tamoxifen (for either 2 to 3 years or 5 years) followed by
aromatase inhibitors for 2 to 3, or 5 years (ASCO guidelines include narrative rankings). (ASCO)
Patients intolerant of aromatase inhibitors should receive tamoxifen. Women with hormone
receptor–negative tumors should not receive adjuvant endocrine therapy (ASCO guidelines include
narrative rankings). (ASCO)
Patients with invasive breast cancers that are estrogen or progesterone receptor positive should be
considered for adjuvant endocrine therapy regardless of patient age, lymph node status, or
whether or not adjuvant chemotherapy is to be administered (Category 2A). (NCCN)
The most firmly established adjuvant endocrine therapy is tamoxifen for both premenopausal and
postmenopausal women. Prospective, randomized trials demonstrate that the optimal duration of
tamoxifen appears to be five years. In patients receiving both tamoxifen and chemotherapy,
chemotherapy should be given first, followed by sequential tamoxifen. Several studies have
evaluated aromatase inhibitors in the treatment of postmenopausal women with early-stage breast
cancer (Category 2A). (NCCN)

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Measure #72: Chemotherapy for Stage III Colon Cancer Patients
DESCRIPTION:
Percentage of patients aged 18 years and older with Stage IIIA through IIIC colon cancer who are
prescribed or who have received adjuvant chemotherapy during the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with colon
cancer seen during the reporting period. It is anticipated that clinicians who treat patients with
Stage IIIA through IIIC colon cancer will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who are prescribed or who have previously received adjuvant chemotherapy* during the
12 month reporting period
Definition: *According to current NCCN guidelines, the following therapies are
recommended: 5-fluorouracil/leucovorin or capecitabine, or 5-fluorouracil/leucovorin/
oxaliplatin
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Adjuvant Chemotherapy Prescribed or Previously Received
(Two CPT II codes [4180F & 33xxF] are required on the claim form to submit this category)
CPT II 4180F: Adjuvant chemotherapy prescribed or previously received for Stage IIIA
through Stage IIIC colon cancer
AND
CPT II 3309F: AJCC Cancer Stage IIIA, documented
OR
CPT II 3310F: AJCC Cancer Stage IIIB, documented
OR
CPT II 3311F: AJCC Cancer Stage IIIC, documented

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OR

Adjuvant Chemotherapy not Prescribed or Previously Received for Medical, Patient,
or System Reasons
(Two CPT II codes [4180F-xP & 33xxF] are required on the claim form to submit this
category)
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4180F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4180F with 1P: Documentation of medical reason(s) for not prescribing adjuvant
chemotherapy (eg, medical comorbidities, diagnosis date more than 5 years prior to
the current visit date; patient’s cancer has metastasized; medical
contraindication/allergy, poor performance status)
• 4180F with 2P: Documentation of patient reason(s) for not prescribing adjuvant
chemotherapy (eg, patient refusal)
• 4180F with 3P: Documentation of system reason(s) for not prescribing adjuvant
chemotherapy (eg, patient is currently enrolled in a clinical trial that precludes
prescription of chemotherapy)
AND
CPT II 3309F: AJCC Cancer Stage IIIA, documented
OR
CPT II 3310F: AJCC Cancer Stage IIIB, documented
OR
CPT II 3311F: AJCC Cancer Stage IIIC, documented
OR
If patient is not eligible for this measure because patient is not stage IIIA through
IIIC colon cancer, report:
Patient not Stage IIIA through IIIC Colon Cancer
(One CPT II code [33xxF] is required on the claim form to submit this category)
Report 3304F for all Stage 1 colon cancers
CPT II 3302F: AJCC Cancer Stage 0, documented
OR
CPT II 3304F: AJCC Cancer Stage IB, documented
OR
CPT II 3306F: AJCC Cancer Stage IIA, documented
OR
CPT II 3307F: AJCC Cancer Stage IIB, documented
OR
CPT II 3312F: AJCC Cancer Stage IV, documented
OR

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If patient is not eligible for this measure because cancer stage is not documented,
report:
Cancer Stage not Documented
(One CPT II code [3309F-8P] is required on the claim form to submit this category)

OR

Append a reporting modifier (8P) to CPT Category II code 3309F to report circumstances
when the patient is not eligible for the measure.
Note: 3309F-8P is being used to indicate that there is no cancer stage documented.
• 3309F with 8P: No documentation of cancer stage
Adjuvant Chemotherapy not Prescribed or Previously Received, Reason not
Specified
(Two CPT II codes [4180F-8P & 33xxF] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4180F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4180F with 8P: Adjuvant chemotherapy not prescribed or previously received, reason
not otherwise specified
AND
CPT II 3309F: AJCC Cancer Stage IIIA, documented
OR
CPT II 3310F: AJCC Cancer Stage IIIB, documented
OR
CPT II 3311F: AJCC Cancer Stage IIIC, documented

DENOMINATOR:
All patients aged 18 years and older with Stage IIIA through IIIC colon cancer
Denominator Coding:
An ICD-9 diagnosis code for colon cancer and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8,
153.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Patients with Stage IIIA through Stage IIIC colon cancer do not always receive the recommended
treatment of adjuvant chemotherapy. This measure is intended to determine whether and how
often chemotherapy is administered. The specific chemotherapy drugs specified in this measure
reflect the most current guidelines of the National Comprehensive Cancer Network.

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CLINICAL RECOMMENDATION STATEMENTS:
Following primary surgical treatment, the panel recommends six months of 5-fluorouracil/leucovorin
capecitabine, or 5-fluorouracil/leucovorin/oxaliplatin as adjuvant chemotherapy for patients with
stage III (T1-4, N1-2, M0) colon cancer (Category 2A). (NCCN)

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Measure #73: Plan for Chemotherapy Documented Before Chemotherapy Administered
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who
are receiving intravenous chemotherapy for whom the planned chemotherapy regimen (which
includes, at a minimum: drug(s) prescribed, dose, and duration) is documented prior to the initiation
of a new treatment regimen
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with breast,
colon, or rectal cancer seen during the reporting period. It is anticipated that clinicians who treat
patients with breast, colon, or rectal cancer who are receiving intravenous chemotherapy
administration will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes and CPT procedure codes are used to identify
patients who are included in the measure’s denominator. CPT Category II codes are used to report
the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
CPT procedure codes, and the appropriate CPT Category II codes OR the CPT Category II code(s)
with the modifier. The modifier allowed for this measure is: 8P- reasons not otherwise specified.
There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients for whom the planned chemotherapy regimen (which includes, at a minimum: drug(s)
prescribed, dose, and duration) is documented prior to the initiation of a new treatment regimen
Numerator Coding:
Plan for Chemotherapy Documented
CPT II 0519F: Planned chemotherapy regimen, including at a minimum: drug(s)
prescribed, dose, and duration, documented prior to initiation of a new treatment regimen
OR

Plan for Chemotherapy not Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 0519F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Plan for chemotherapy not documented, reason not otherwise specified

DENOMINATOR:
All patients, regardless of age, with a diagnosis of breast, colon, or rectal cancer who are receiving
intravenous chemotherapy

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Denominator Coding:
An ICD-9 diagnosis code for breast, colon, or rectal cancer, a CPT E/M service code and a
CPT procedure code for intravenous chemotherapy administration are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8,
153.9, 154.0, 154.1, 154.2, 154.3, 154.8, 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6,
174.8, 174.9
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
AND
CPT procedure codes: 96401, 96402, 96405, 96406, 96409, 96411, 96413, 96415,
96416, 96417, 96420, 96422, 96423, 96425, 96440, 96445, 96450, 96521, 96522, 96523,
96542, 96549
RATIONALE:
A detailed plan for the chemotherapy regimen is a critical component of ensuring high quality care
for patients. There are no exclusions for this measure.
CLINICAL RECOMMENDATION STATEMENTS:
American Society of Clinical Oncology, “Chemotherapy Treatment Summary,” specifies that a
treatment plan should include the following information about the planned chemotherapy regimen:
• Chemotherapy regimen and starting dosages
• Duration of treatment and number of planned cycles (ASCO)

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Measure #74: Radiation Therapy Recommended for Invasive Breast Cancer Patients Who
Have Undergone Breast Conserving Surgery
DESCRIPTION:
Percentage of invasive female breast cancer patients aged 18 through 70 years old who have
undergone breast conserving surgery and who have received recommendation for radiation
therapy within 12 months of the first office visit
INSTRUCTIONS:
This measure is to be reported a minimum once per reporting period for female breast cancer
patients at the time of the initial office visit. It is anticipated that clinicians who care for patients with
invasive breast cancer and provide radiation therapy will submit this measure.
This measure is reported using G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. G-codes are used to
report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Female patients with invasive breast cancer patients aged 18 to 70 years old who have undergone
breast conserving surgery and who then receive recommendation for radiation therapy within 12
months of the first office visit.
Numerator Instruction: The numerator code should be reported at the time of radiation
therapy services.
Definition: Radiation therapy may include external beam radiation or brachytherapy.
Numerator Coding:
Radiation Therapy Recommended
G8379: Documentation of radiation therapy recommended within 12 months of first office
visit
OR

OR

Radiation Therapy not Recommended for Documented Reasons
G8378: Clinician documentation that patient was not an eligible candidate for radiation
therapy measure
Radiation Therapy not Recommended
G8383: No documentation of radiation therapy recommended within 12 months of first
office visit

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DENOMINATOR:
All female patients aged 18 through 70 years with invasive breast cancer
Denominator Coding:
An ICD-9 diagnosis code for invasive breast cancer and a CPT E/M service code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9
AND
CPT E/M service codes: 99241, 99242, 99243, 99244, 99245
RATIONALE:
Data from multiple large randomized trials have demonstrated that the addition of radiation after
breast conserving surgery in patients with invasive breast cancer lowers the risk of local
recurrence. The Oxford meta-analysis of these studies (Peto, et. al., Lancet, 2006) has also
detected an improvement in overall survival with the use of radiation therapy in this setting.
CLINICAL RECOMMENDATION STATEMENTS:
Refer to the National Comprehensive Cancer Network Breast Cancer guideline recommendations
v2.2006, BINV-2.
The National Quality Forum is in the process of approving the National Voluntary Consensus
Standards for Diagnosis and Treatment of Breast and Colon Cancer, which includes a measure at
the facility level for radiation therapy for patients who have had breast conserving surgery for
accountability purposes.

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Measure #75: Prevention of Ventilator-Associated Pneumonia – Head Elevation
DESCRIPTION:
Percentage of ICU patients aged 18 years and older who receive mechanical ventilation and who
had an order on the first ventilator day for head of bed elevation (30-45 degrees)
INSTRUCTIONS:
This measure is to be reported once for each episode of care for all critically ill patients seen during
the reporting period. There is no diagnosis associated with this measure. An individual patient may
have multiple ICU episodes during the same hospitalization. This measure should be reported for
each new episode of care, even those that occur during the same hospitalization.
Situations that define an episode include the following:
1) The first instance 99291 is used (e.g., admission to the ICU or a new episode of critical
care)
2) Upon readmission to the ICU from another unit (e.g., discharged to a step-down unit,
then readmitted to ICU due to complications)
3) *Upon reintubation or intubation any time following admission to the ICU
*The following is an example: For the patient initially admitted to the ICU, not receiving
ventilation, CPT II 4169F (see coding below) would be reported. There may be instances
when a critically ill patient is not ventilated at the initial instance of 99291; if the patient’s
status changes during the episode, requiring ventilation, a second CPT II code (4168F)
indicating that the patient is receiving ventilation should be reported; finally, if head of bed
elevation is ordered, report CPT II code 4167F.
It is anticipated that clinicians who provide care in the ICU will submit this measure. Clinicians
utilizing the critical care code in the emergency department will not be included in this measure.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes and the appropriate CPT
Category II code(s) OR the CPT Category II code(s) with the modifier. The modifiers allowed for
this measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who had an order on the first ventilator day for head of bed elevation (30-45 degrees)
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Order for Head of Bed Elevation (30-45 degrees) on First Ventilator Day
(Two CPT II codes [4167F & 4168F] are required on the claim form to submit this
category)

OR

CPT II 4167F: Head of bed elevation (30-45 degrees) on first ventilator day ordered
AND
CPT II 4168F: Patient receiving care in the intensive care unit (ICU) and receiving
mechanical ventilation, 24 hours or less
Head of Bed Elevation (30-45 Degrees) not Ordered on First Ventilator Day for
Medical Reasons
(Two CPT II codes [4167F-1P & 4168F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II code 4167F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4167F with 1P: Documentation of medical reason(s) for not ordering head of bed
elevation (30-45 degrees) on the first ventilator day
AND
CPT II 4168F: Patient receiving care in the intensive care unit (ICU) and receiving
mechanical ventilation, 24 hours or less
OR

OR

CPT II 4169F: Report if patient is not eligible for this measure because patient is not
receiving ICU care or not receiving mechanical ventilation.
Head of Bed Elevation (30-45 Degrees) not Ordered on First Ventilator Day, Reason
not Specified
(Two CPT II codes [4167F-8P & 4168F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4167F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4167F with 8P: Head of bed elevation (30-45 degrees) not ordered on first ventilator
day, reason not otherwise specified
AND
CPT II 4168F: Patient receiving care in the intensive care unit (ICU) and receiving
mechanical ventilation, 24 hours or less

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DENOMINATOR:
All patients aged 18 years and older receiving care in the ICU who receive mechanical ventilation
Definition: For the purposes of this measure, mechanical ventilation may include pressure
or volume preset ventilators for assisted or controlled breathing OR continuous positive
airway pressure ventilation (CPAP).
Denominator Coding:
An E/M service code is required to identify patients for denominator inclusion.
CPT E/M service code: 99291*
*Clinicians indicating the place of service as the emergency department will not be
included in this measure.
RATIONALE:
Mechanically ventilated patients are at high risk for aspiration pneumonia. Elevation of the head of
the bed has been shown to reduce the risk of aspiration.
Existing hospital-level measures for this topic were consulted and, to the extent feasible,
harmonization between physician- and hospital-level measurement was achieved.
CLINICAL RECOMMENDATION STATEMENTS:
Patients should be kept in the semi-recumbent position (30–45°) rather than supine to prevent
aspiration, especially when receiving enteral feeding. (ATS/IDSA) (Level I)
In the absence of medical contraindication(s), elevate at an angle of 30-45 degrees the head of the
bed of a patient at high risk for aspiration pneumonia (e.g., a person receiving mechanically
assisted ventilation or who has an enteral tube in place). (CDC) (Category I)

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Measure #76: Prevention of Catheter-Related Bloodstream Infections (CRBSI) – Central
Venous Catheter Insertion Protocol
DESCRIPTION:
Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for
whom CVC was inserted with all elements of maximal sterile barrier technique (cap AND mask
AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2%
chlorhexidine for cutaneous antisepsis) followed
INSTRUCTIONS:
This measure is to be reported each time a CVC insertion is performed during the reporting period.
There is no diagnosis associated with this measure. It is anticipated that clinicians who perform
CVC insertion will submit this measure.
This measure is reported using CPT Category II codes:
CPT procedure codes are used to identify patients who are included in the measure’s denominator.
CPT Category II codes are used to report the numerator of the measure.
When reporting the measure, submit the listed CPT procedure codes and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile
barrier technique (cap AND mask AND sterile gown AND sterile gloves AND a large sterile sheet
AND hand hygiene AND 2% chlorhexidine for cutaneous antisepsis) followed
Definition: For purposes of this measure, maximal sterile barrier technique during CVC
insertion is defined to include use of: cap AND mask AND sterile gown AND sterile gloves
AND a large sterile sheet AND hand hygiene AND 2% chlorhexidine for cutaneous
antisepsis.
Numerator Coding:
All Elements of Maximal Sterile Barrier Technique Followed
CPT II 6030F: All elements of maximal sterile barrier technique including: cap AND mask
AND sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND
2% chlorhexidine for cutaneous antisepsis, followed
OR

All Elements of Maximal Sterile Barrier Technique not Followed for Medical Reasons
Append a modifier (1P) to CPT Category II code 6030F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not following all elements of maximal
sterile barrier technique during CVC insertion (including CVC insertion performed on
emergency basis)

OR

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All Elements of Maximal Sterile Barrier Technique not Followed, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 6030F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: All elements of maximal sterile barrier technique including: cap AND mask AND
sterile gown AND sterile gloves AND a large sterile sheet AND hand hygiene AND 2%
chlorhexidine for cutaneous antisepsis, not followed reason not otherwise specified
DENOMINATOR:
All patients, regardless of age, who undergo CVC insertion
Denominator Coding:
A CPT procedure code for CVC insertion or replacement is required to identify patients for
denominator inclusion.
CPT procedure codes: 36555, 36556, 36557, 36558, 36560, 36561, 36563, 36565,
36566, 36568, 36569, 36570, 36571, 36578, 36580, 36581, 36582, 36583, 36584, 36585
RATIONALE:
Catheter-related bloodstream infection is a costly complication of central venous catheter insertion,
but may be avoided with routine use of aseptic technique during catheter insertion. This measure is
constructed to require that all of the listed elements of aseptic technique are followed and
documented.
Existing hospital-level measures for this topic were consulted and, to the extent feasible,
harmonization between physician- and hospital-level measurement was achieved.
CLINICAL RECOMMENDATION STATEMENTS:
Maximal sterile barrier precautions during catheter insertion: Use aseptic technique including the
use of a cap, mask, sterile gown, sterile gloves, and a large sterile sheet, for the insertion of CVCs
(including PICCS) or guidewire exchange. (CDC/MMWR) (Category IA)
Hand hygiene: Observe proper hand-hygiene procedures either by washing hands with
conventional antiseptic-containing soap and water or with waterless alcohol-based gels or foams.
Observe hand hygiene before and after palpating catheter insertion sites, as well as before and
after inserting, replacing, accessing, repairing, or dressing an intravascular catheter. Palpation of
the insertion site should not be performed after the application of antiseptic, unless aseptic
technique is maintained. Use of gloves does not obviate the need for hand hygiene. (CDC/MMWR)
(Category IA)
Cutaneous antisepsis: Disinfect clean skin with an appropriate antiseptic before catheter insertion
and during dressing changes. Although a 2% chlorhexidine-based preparation is preferred, tincture
of iodine, an iodophor, or 70% alcohol can be used. (CDC/MMWR) (Category IA)

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Measure #77: Assessment of GERD Symptoms in Patients Receiving Chronic Medication
for GERD
DESCRIPTION:
Percentage of patients aged 18 years and older with the diagnosis of gastroesophageal reflux
disease (GERD) who have been prescribed continuous proton pump inhibitor (PPI) or histamine H2
receptor antagonist (H2RA) therapy who received an annual assessment of their GERD symptoms
after 12 months of therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with GERD
seen during the reporting period. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator and denominator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who had an annual assessment of their GERD symptoms after 12 months of therapy
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
GERD Symptoms Assessed
(Two CPT II codes [1118F & 4185F] are required on the claim form to submit this
category)

OR

CPT II 1118F: GERD symptoms assessed after 12 months of therapy
AND
CPT II 4185F: Continuous (12-months) therapy with proton pump inhibitor (PPI) or
histamine H2 receptor antagonist (H2RA) received

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GERD Symptoms not Assessed for Medical Reasons
(Two CPT II codes [1118F-1P & 4185F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II code 1118F to report documented
circumstances that appropriately exclude patients from the denominator
• 1118F with 1P: Documentation of medical reason(s) for not assessing GERD
symptoms
AND
CPT II 4185F: Continuous (12-months) therapy with proton pump inhibitor (PPI) or
histamine H2 receptor antagonist (H2RA) received
OR
If patient is not eligible for this measure because patient was not prescribed
continuous medication therapy, report:
(One CPT II code [4186F] is required on the claim form to submit this category)

OR

CPT II 4186F: No continuous (12-months) therapy with either proton pump inhibitor (PPI)
or histamine H2 receptor antagonist (H2RA) received
GERD Symptoms not Assessed, Reason not Specified
(Two CPT II codes [1118F-8P & 4185F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 1118F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 1118F with 8P: GERD symptoms not assessed after 12 months of therapy, reason not
otherwise specified
AND
CPT II 4185F: Continuous (12-months) therapy with proton pump inhibitor (PPI) or
histamine H2 receptor antagonist (H2RA) received

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of GERD who have been prescribed
continuous proton pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy
Definition: Continuous medication therapy is defined as any patient receiving proton
pump inhibitor (PPI) or histamine H2 receptor antagonist (H2RA) therapy lasting 12 months
or more to treat GERD.

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Denominator Coding:
An ICD-9 diagnosis code for gastroesophageal reflux disease and a CPT E/M service code
are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 530.10, 530.11, 530.12, 530.19, 530.81
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Many patients with GERD remain on medication therapy for years, and experts suspect that not all
patients are being reassessed on a regular basis to determine whether the medication is still
needed. This measure attempts to capture whether or not a patient on chronic medication have
their GERD symptoms are assessed at least annually. Research indicates that patients on chronic
therapy are able to have their dose modified or reduced based on the presence or absence of
symptoms.
CLINICAL RECOMMENDATION STATEMENTS:
Because GERD is a chronic condition, continuous therapy to control symptoms and prevent
complications is appropriate. (ACG)
Nonresponders to adequate trials of drug therapy, particularly PPI therapy, should have their
symptoms reassessed, undergo endoscopy if it was not previously done, and be considered for
additional diagnostic work-up. (VHA/DOD)
Inadequate response to a 4- to 8-week course of standard-dose PPI may indicate longer treatment
is needed, more severe disease, or incorrect diagnosis. If there is an adequate response to a
course of standard-dose PPI (the recommended duration of therapy for PPIs in the treatment of
GERD is 4 to 8 weeks), extend treatment with either the same or double dose of PPI. (VHA/DOD)

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Measure #78: Vascular Access for Patients Undergoing Hemodialysis
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of end stage renal disease
(ESRD) and receiving hemodialysis who have a functioning AV fistula OR patients who are
referred for an AV fistula at least once during the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for ESRD patients receiving
hemodialysis seen during the reporting period. It is anticipated that clinicians providing care for
patients with ESRD will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, Gcodes and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons,
8P- reasons not otherwise specified.
NUMERATOR:
Patients who have a functioning AV fistula OR patients who are referred for AV fistula at least once
during the 12 month reporting period
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Patient with Functioning AV Fistula
(One CPT II code [4052F] is required on the claim form to submit this category)
CPT II 4052F: Hemodialysis via functioning arterio-venous (AV) fistula
OR
Patient Referred for AV Fistula
(Two CPT II codes [4051F & 4054F] are required on the claim form to submit this
category)
CPT II 4051F: Referred for an arterio-venous (AV) fistula
AND
CPT II 4054F: Hemodialysis via catheter

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OR

Patient not Referred for AV Fistula for Medical or Patient Reasons
(Two CPT II codes [4051F-xP & 4054F] are required on the claim form to submit this
category)
Append a modifier (1P or 2P) to CPT Category II code 4051F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4051F with 1P: Documentation of medical reason(s) for not referring for an AV fistula
• 4051F with 2P: Documentation of patient reason(s) for not referring for an AV fistula
AND
CPT II 4054F: Hemodialysis via catheter
OR
If patient is not eligible for this measure because patient has a functioning arteriovenous (AV) graft, report:
(One CPT II code [4053F] is required on the claim form to submit this category)

OR

CPT II 4053F: Hemodialysis via functioning arterio-venous (AV) graft
Patient not Referred for AV Fistula, Reason not Specified
(Two CPT II codes [4051F-8P & 4054F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II codes 4051F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4051F with 8P: Patient was not referred for an AV fistula, reason not otherwise
specified
AND
CPT II 4054F: Hemodialysis via catheter

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of ESRD and receiving hemodialysis
Denominator Coding:
An ICD-9 diagnosis code for ESRD and a G-code or CPT procedure code for hemodialysis
are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 585.6
AND
CPT procedure codes or G-codes: 90935, 90937, G0314, G0315, G0316, G0317,
G0318, G0319

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RATIONALE:
A functioning AV fistula is the preferred delivery method for hemodialysis. This measure assesses
two components: 1) whether patients have a functioning AV fistula, or 2) if not, was the patient
referred for an AV fistula or permanent vascular access at least once during the reporting year.
This measure captures actions that are within a nephrologist’s control (e.g., referral) rather than
simply measuring the percentage of patients who have an AV fistula.
CLINICAL RECOMMENDATION STATEMENTS:
Patients should have a functional permanent access at the initiation of dialysis therapy. A fistula
should be placed at least 6 months before the anticipated start of HD treatments. This timing allows
for access evaluation and additional time for revision to ensure a working fistula is available at
initiation of dialysis therapy. (B) A graft should, in most cases, be placed at least 3 to 6 weeks
before the anticipated start of HD therapy. Some newer graft materials may be cannulated
immediately after placement. (B) A peritoneal dialysis (PD) catheter ideally should be placed at
least 2 weeks before the anticipated start of dialysis treatments. A backup HD access does not
need to be placed in most patients. A PD catheter may be used as a bridge for a fistula in
“appropriate” patients. (B) (KDOQITM )

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Measure #79: Influenza Vaccination in Patients with End Stage Renal Disease (ESRD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis
who received the influenza immunization during the flu season (September through February)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for ESRD patients receiving
dialysis seen during the reporting period. This measure is intended to determine whether or not
ESRD patients receiving dialysis received or had an order for influenza immunization during the flu
season. It is anticipated that clinicians providing care for patients with ESRD will submit this
measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, Gcodes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 3P- system
reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who received the influenza immunization during the flu season (September through
February)

OR

OR

Numerator Coding:
Influenza Immunization Received
CPT II 4037F: Influenza immunization ordered or administered
Influenza Immunization not Received for Medical, Patient, or System Reasons
Append a modifier (1P, 2P, or 3P) to CPT Category II code 4037F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for patient not receiving the influenza
immunization
• 2P: Documentation of patient reason(s) for patient not receiving the influenza
immunization
• 3P: Documentation of system reason(s) for patient not receiving the influenza
immunization

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Influenza Immunization not Received, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4037F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Influenza immunization not ordered or administered, reason not otherwise
specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of ESRD and receiving dialysis
Denominator Coding:
An ICD-9 diagnosis code for ESRD and a G-code or CPT procedure code for dialysis are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 585.6
AND
CPT procedure codes or G-codes: 90935, 90937, 90945, 90947, G0314, G0315,
G0316, G0317, G0318, G0319, G0322, G0323, G0326, G0327
RATIONALE:
Infectious disease is a common cause of death in late-stage kidney disease patients. Immunizing
this high risk population is therefore critical to increasing patient well-being and potentially reducing
morbidity and mortality. Despite its importance, a review of Medicare billing data has indicated that
the ESRD population had a less than 50% immunization rate for the years 1997 to 1998 and 1998
to 1999.
CLINICAL RECOMMENDATION STATEMENTS:
Annual influenza vaccine is recommended for all persons aged 65 and older and persons in
selected high-risk groups. (B recommendation) (USPSTF)
Vaccination is recommended for the following persons who are at increased risk for complications
from influenza: adults and children who have required regular medical follow-up or hospitalization
during the preceding year because of chronic metabolic diseases (including diabetes mellitus),
renal dysfunction, hemoglobinopathies, or immunosuppression (including immunosuppression
caused by medications or by human immunodeficiency virus [HIV]); (CDC).

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Measure #80: Plan of Care for ESRD Patients with Anemia
DESCRIPTION:
Percentage of patient calendar months during the 12-month reporting period in which patients aged
18 years and older with a diagnosis of end stage renal disease (ESRD) who are receiving dialysis
have a Hgb ≥ 11g/dL OR have a Hgb < 11 g/dL with a documented plan of care for anemia
INSTRUCTIONS:
This measure is to be reported each calendar month dialysis is performed on ESRD patients seen
during the reporting period. It is anticipated that clinicians providing care for patients with ESRD will
submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, Gcodes and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifier allowed for this measure is: 8P- reasons not otherwise specified. There are
no allowable performance exclusions for this measure.
NUMERATOR:
Number of patient calendar months during which patients have a Hgb ≥ 11 g/dL OR have a Hgb <
11 g/dL with a documented plan of care for anemia
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Patient has Hemoglobin Level ≥ 11 g/dL
(One CPT II code [32xxF] is required on the claim form to submit this category)
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
OR
CPT II 3280F: Hemoglobin level 11 g/dL to 12.9 g/dL
OR

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Patient has Hemoglobin < 11 g/dL with a Documented Plan of Care
(Two CPT II codes [3281F & 0516F] are required on the claim form to submit this
category)

OR

CPT II 3281F: Hemoglobin less than 11 g/dL
AND
CPT II 0516F: Anemia plan of care documented
Hemoglobin Level not Performed or Documented
(Two CPT II codes [3279F] are required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 3279F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3279F with 8P: Hemoglobin level was not performed or documented, reason not
otherwise specified
OR
Patient has Hemoglobin Level < 11 g/dL without a Documented Plan of Care, Reason
Not Specified
(Two CPT II codes [0516F-8P & 3281F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II codes 0516F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 0516F with 8P: Anemia plan of care not documented, reason not otherwise specified
AND
CPT II 3281F: Hemoglobin less than 11g/dL

DENOMINATOR:
Calendar months during which all patients aged 18 years and older with a diagnosis of ESRD are
receiving dialysis
Denominator Coding:
An ICD-9 diagnosis code for ESRD and a G-code or CPT procedure code for dialysis are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 585.6
AND
CPT procedure codes or G-codes: 90935, 90937, 90945, 90947, G0314, G0315,
G0316, G0317, G0318, G0319, G0322, G0323, G0326, G0327

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RATIONALE:
Anemia is a common comorbidity in patients with kidney disease, increasing in likelihood as kidney
function declines. The goal of this measure is to identify anemia and develop a treatment plan
which is vital to “improve patient quality of life, to improve the various physiological abnormalities
associated with anemia, to decrease morbidity, to decrease hospitalization, and to improve patient
survival.”
CLINICAL RECOMMENDATION STATEMENTS:
Hb testing should be carried out in all patients with CKD, regardless of stage or cause (Opinion).
Hb levels should be measured at least annually (Opinion). In patients with CKD, Hb should be 11.0
g/dL or greater (Moderately Strong Recommendation). (KDOQITM)

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Measure #81: Plan of Care for Inadequate Hemodialysis in ESRD Patients
DESCRIPTION:
Percentage of patient calendar months during the 12-month reporting period in which patients aged
18 years and older with a diagnosis of end stage renal disease (ESRD) receiving hemodialysis
have a Kt/V ≥ 1.2 OR patients who have a Kt/V < 1.2 with a documented plan of care for
inadequate hemodialysis
INSTRUCTIONS:
This measure is to be each calendar month hemodialysis is performed on ESRD patients seen
during the reporting period. It is anticipated that clinicians providing care for patients with ESRD will
submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, G-codes and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, Gcodes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifier allowed for this measure is: 8P- reasons not otherwise specified. There are
no allowable performance exclusions for this measure.
NUMERATOR:
Number of patient calendar months during which patients have a Kt/V ≥1.2 OR have Kt/V <1.2 with
a documented plan of care for inadequate hemodialysis
Definition: A documented plan of care may include checking for adequacy of the AV
access, increasing the blood flow, increasing the dialyzer size, increasing the time of
dialysis sessions, adjusting dialysis prescription, or documenting residual renal function.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Kt/V ≥ 1.2
(One CPT II code [30xxF] is required on the claim form to submit this category)
CPT II 3083F: Kt/V equal to or greater than 1.2 and less than 1.7 (Clearance of urea
(Kt)/volume(V))
OR
CPT II 3084F: Kt/V ≥1.7 (Clearance of urea (Kt)/volume(V))
OR

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Kt/V < 1.2 with a Documented Plan of Care
(Two CPT II codes [3082F & 0505F] are required on the claim form to submit this
category)

OR

CPT II 3082F: Kt/V < 1.2 (Clearance of urea (Kt)/volume(V))
AND
CPT II 0505F: Hemodialysis plan of care documented
Kt/V Measurement not Performed or Documented
(One CPT II code [3084F-8P] is required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 3084F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified
• 3084F with 8P: Kt/V was not performed or documented, reason not otherwise
specified
OR
Patient has Kt/V < 1.2 without a Documented Plan of Care, Reason not Specified
(Two CPT II codes [0505F-8P & 3082F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II codes 0505F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 0505F with 8P: Hemodialysis plan of care not documented, reason not otherwise
specified
AND
CPT II 3082F: Kt/V < 1.2 (Clearance of urea (Kt)/volume(V))

DENOMINATOR:
Calendar months for all patients aged 18 years and older with a diagnosis of ESRD who are
receiving hemodialysis
Denominator Coding:
An ICD-9 diagnosis code for ESRD and a G-code or CPT procedure code for hemodialysis
are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 585.6
AND
CPT procedure codes or G-codes: 90935, 90937, G0314, G0315, G0316, G0317,
G0318, G0319

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RATIONALE:
Patients receiving hemodialysis must be monitored (by assessing Kt/V) regularly to ensure that
their dialysis dose is sufficient. A patient receiving hemodialysis whose Kt/V level is less than 1.2 is
not receiving optimal dialysis. This measure assesses whether the treating physician addressed
the low Kt/V level. A plan of care (action defined as checking for adequacy of the AV access,
increasing the blood flow, increasing the dialyzer size, or increasing the time of dialysis sessions)
should be documented by the physician for every time Kt/V is less than 1.2.
CLINICAL RECOMMENDATION STATEMENTS:
Quantifying HD is the first step toward assessment of its adequacy. Fortunately, the intermittent
rapid decrease in urea concentration during HD allows a relatively easy measurement of the dose.
The delivered dose of HD should be measured at regular intervals no less than monthly(A).
(KDOQITM )
The minimally adequate dose of HD given 3 times per week to patients with Kr less than 2
mL/min/1.73 m2 should be an spKt/V (excluding RKF) of 1.2 per dialysis. For treatment times less
than 5 hours, an alternative minimum dose is a URR of 65% (A). The target dose for HD given 3
times per week with Kr less than 2 mL/min/1.73 m2 should be an spKt/V of 1.4 per dialysis not
including RKF, or URR of 70% (A). (KDOQITM)

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Measure #82: Plan of Care for Inadequate Peritoneal Dialysis
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of end stage renal disease
(ESRD) receiving peritoneal dialysis who have a Kt/V ≥ 1.7 OR patients who have a Kt/V < 1.7 with
a documented plan of care for inadequate peritoneal dialysis at least three times during the 12month reporting period
INSTRUCTIONS:
This measure is to be reported up to three times per reporting year for ESRD patients receiving
peritoneal dialysis during the entire reporting period and seen during the reporting period.
This measure should be reported according to the following frequency, depending on the number
of months during the reporting period a patient is receiving peritoneal dialysis:
• 1-4 months- report once during the reporting period
• 5-8 months- report twice during the reporting period
• 9-12 months- report three times during the reporting period
It is anticipated that clinicians providing care for patients with ESRD will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, G-codes, and patient demographics (age, gender,
etc.) are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes, Gcodes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifier allowed for this measure is: 8P- reasons not otherwise specified. There are
no allowable performance exclusions for this measure.
NUMERATOR:
Patients who have a Kt/V ≥1.7 OR have a Kt/V <1.7 with a documented plan of care for inadequate
peritoneal dialysis at least three times during the 12 month reporting period
Definition: A documented plan of care may include assessing for non-adherence with the
peritoneal prescription, sampling, and collection; assessing for error in the peritoneal
dialysis prescription and/or inadequate monitoring of the delivered dose; performing
peritoneal equilibrium testing; assessing for inadequate patient education; increasing the
exchange volume; increasing the number of exchanges per 24 hours; assessing for
modality (CAPD or CCPD).
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Kt/V ≥ 1.7
(One CPT II code [3084F] is required on the claim form to submit this category)
CPT II 3084F: Kt/V ≥1.7 (Clearance of urea (Kt)/volume(V))
OR
Kt/V < 1.7 with a Documented Plan of Care
(Two CPT II codes [30xxF & 0507F] are required on the claim form to submit this category)
CPT II 3083F: Kt/V equal to or greater than 1.2 and less than 1.7 (Clearance of urea
(Kt)/volume(V))
OR
CPT II 3082F: Kt/V < 1.2 (Clearance of urea (Kt)/volume(V))
AND
CPT II 0507F: Peritoneal dialysis plan of care documented
OR

Kt/V not Performed or Documented
(One CPT II code [3084F-8P] is required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 3084F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified
• 3084F with 8P: Kt/V was not performed or documented, reason not otherwise
specified
OR
Patient has Kt/V < 1.7 without a Documented Plan of Care, Reason not Specified
(Two CPT II codes [0507F-8P & 30xxF] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II codes 0507F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 0507F with 8P: Peritoneal dialysis plan of care not documented, reason not otherwise
specified
AND
CPT II 3082F: Kt/V < 1.2 (Clearance of urea (Kt)/volume(V))
OR
CPT II 3083F: Kt/V equal to or greater than 1.2 and less than 1.7 (Clearance of urea
(Kt)/volume(V))

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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of ESRD receiving peritoneal dialysis
Denominator Coding:
An ICD-9 diagnosis code for ESRD and a G-code or CPT procedure code for peritoneal
dialysis are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 585.6
AND
CPT procedure codes or G-codes: 90945, 90947, G0322, G0323, G0326, G0327
RATIONALE:
Patients receiving peritoneal dialysis must be monitored (by assessing Kt/V) regularly to ensure
that their dialysis dose is sufficient. A patient receiving peritoneal dialysis whose Kt/V level is less
than 1.7 is not receiving optimal dialysis. This measure assesses whether the treating physician
addressed the low Kt/V level. A plan of care (may include assessing for non-adherence with the
peritoneal prescription, sampling, and collection; assessing for error in the peritoneal dialysis
prescription and/or inadequate monitoring of the delivered dose; performing peritoneal equilibrium
testing; assessing for inadequate patient education; increasing the exchange volume; or increasing
the number of exchanges per 24 hours) should be documented by the physician for every time Kt/V
is less than 1.7.
CLINICAL RECOMMENDATION STATEMENTS:
Total solute clearance (residual kidney and peritoneal, in terms of Kt/Vurea) should be measured
within the first month after initiating dialysis therapy and at least once every 4 months thereafter
(B). (KDOQITM)
For patients with residual kidney function (considered to be significant when urine volume is > 100
mL/d): The minimal “delivered” dose of total small-solute clearance should be a total (peritoneal
and kidney) Kt/Vurea of at least 1.7 per week (B).
For patients without RKF (considered insignificant when urine volume is ≤ 100 mL/d): The minimal
“delivered” dose of total small-solute clearance should be a peritoneal Kt/Vurea of at least 1.7 per
week measured within the first month after starting dialysis therapy and at least once every 4
months thereafter (B). (KDOQITM )

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Measure #83: Testing of Patients with Chronic Hepatitis C (HCV) for Hepatitis C Viremia
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C seen for an initial
evaluation who had HCV RNA testing ordered or previously performed
INSTRUCTIONS:
This measure should be reported on the first visit occurring during the reporting period for all
patients with a diagnosis of hepatitis C seen during the reporting period. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients for whom HCV RNA testing was ordered or previously performed
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
RNA Testing Ordered or Results Documented
(Two CPT II codes [3265F & 1119F] are required on the claim form to submit this
category)

OR

CPT II 3265F: Ribonucleic acid (RNA) testing for Hepatitis C viremia ordered or results
documented
AND
CPT II 1119F: Initial evaluation for condition

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RNA Testing not Ordered or Results not Documented for Medical or Patient Reasons
(Two CPT II codes [3265F-xP & 1119F] are required on the claim form to submit this
category)
Append a modifier (1P or 2P) to CPT Category II code 3265F to report documented
circumstances that appropriately exclude patients from the denominator.
• 3265F with 1P: Documentation of medical reason(s) for not ordering or performing
RNA testing for HCV
• 3265F with 2P: Documentation of patient reason(s) for not ordering or performing
RNA testing for HCV
AND
CPT II 1119F: Initial evaluation for condition
OR
If patient is not eligible for this measure because the patient is seen for a
subsequent evaluation for condition, report:
(One CPT II code [1121F] is required on the claim form to submit this category)
CPT II 1121F: Subsequent evaluation for condition
OR

RNA Testing not Ordered or Results not Documented, Reason not Specified
(Two CPT II codes [3265F-8P & 1119F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3265F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3265F with 8P: RNA testing for HCV was not ordered or results not documented,
reason not otherwise specified
AND
CPT II 1119F: Initial evaluation for condition

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C seen for initial evaluation
Denominator Coding:
An ICD-9 diagnosis code for hepatitis C and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.51, 070.54, 070.70
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
HCV RNA testing is needed to establish and confirm diagnosis of chronic hepatitis C. HCV is an
RNA virus of the Flaviviridae family. HCV replicates preferentially in hepatocytes but is not directly
cytopathic, leading to persistent infection. During chronic infection, HCV RNA reaches high levels,
generally ranging from 105 to 107 international units (IU)/mL, but the levels can fluctuate widely.
However, within the same individual, RNA levels are usually relatively stable. (NIH)
After initial exposure, HCV RNA can be detected in blood within 1 to 3 weeks and is present at the
onset of symptoms.
Antibodies to HCV are detected by enzyme immunoassay (EIA) in only 50 to 70 percent of patients
at the onset of symptoms, increasing to more than 90 percent after 3 months.
The clinical utility of serial HCV viral levels in a patient is predicated on continued use of the same
specific quantitative assay that was used in the initial determination of the viral level. While there is
little correlation between disease severity or disease progression with the absolute level of HCV
RNA, quantitative determination of the HCV level provides important information on the likelihood
of response to treatment in patients undergoing antiviral therapy.
CLINICAL RECOMMENDATION STATEMENTS:
HCV ribonucleic acid (RNA) testing should be performed in:
a. patients with a positive anti-HCV test (Grade II-2);
b. patients for whom antiviral treatment is being considered, using a quantitative assay
(Grade II-2);
c. patients with unexplained liver disease whose anti-HCV test is negative and who are
immunocompromised or suspected of having acute HCV infection (Grade II-2). (AASLD)
The diagnosis of chronic hepatitis C infection is often suggested by abnormalities in ALT levels and
is established by EIA followed by confirmatory determination of HCV RNA. (NIH)

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Measure #84: Initial Hepatitis C RNA Testing
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom quantitative HCV RNA testing was performed within 6
months prior to initiation of treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.)
are used to identify patients who are included in the measure’s denominator. CPT Category II
codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes
and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients for whom quantitative HCV RNA testing was performed within 6 months prior to initiation
of treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
RNA Testing Performed within Six Months
(Two CPT II codes [3218F & 4150F] are required on the claim form to submit this
category)

OR

CPT II 3218F: RNA testing for Hepatitis C documented as performed within six months
prior to initiation of antiviral treatment for Hepatitis C
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C

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RNA Testing not Performed within Six Months for Medical Reason
(Two CPT II codes [3218F-1P & 4150F] are required on the claim form to submit this
category)
Append a modifier (1P) to CPT Category II code 3218F to report documented
circumstances that appropriately exclude patients from the denominator.
• 3218F with 1P: Documentation of medical reason(s) for not performing RNA testing
within six months prior to initiation of antiviral treatment for Hepatitis C
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One CPT II code [4151F] is required on the claim form to submit this category)
OR

CPT II 4151F: Patient not receiving antiviral treatment for Hepatitis C
RNA Testing not Performed within Six Months, Reason not Specified
(Two CPT II codes [3218F-8P & 4150F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3218F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3218F with 8P: RNA testing for Hepatitis C was not documented as performed within
six months prior to initiation of antiviral treatment for Hepatitis C, reason not otherwise
specified
AND
CPT II 4150F: Patient receiving antiviral treatment for Hepatitis C

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving
antiviral treatment
Denominator Coding:
An ICD-9 diagnosis code for chronic hepatitis C and a CPT E/M service code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.54
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
Establish baseline level against which to monitor virologic response and indicate likelihood of
response. The clinical utility of serial HCV viral levels in a patient is predicated on continued use of
the same specific quantitative assay that was used in the initial determination of the viral level.
While there is little correlation between disease severity or disease progression with the absolute
level of HCV RNA, quantitative determination of the HCV level provides important information on
the likelihood of response to treatment in patients undergoing antiviral therapy. (NIH)
CLINICAL RECOMMENDATION STATEMENTS:
HCV RNA testing should be performed in patients with a positive anti-HCV test (Grade II-2),
patients for whom antiviral treatment is being considered, using a quantitative assay (Grade II-2),
patients with unexplained liver disease whose anti-HCV test is negative and patients who are
immune compromised or suspected of having acute HCV infection (Grade II-2). AASLD)
All candidates for antiviral therapy should be tested for HCV RNA with a quantitative amplification
assay, which provides both a baseline level against which to monitor virologic response and a
prognostic indicator of the likelihood of response. AGA)
The diagnosis of chronic hepatitis C infection is often suggested by abnormalities in ALT levels and
is established by EIA followed by confirmatory determination of HCV RNA. NIH)

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Measure #85: HCV Genotype Testing Prior to Therapy
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom HCV genotype testing was performed prior to initiation of
treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
This measure is reported using CPT Category II codes and/or G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
and/or G-codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients for whom HCV genotype testing was performed prior to initiation of treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Hepatitis C Genotype Testing Performed
(One CPT II code & one G-code [3266F & G8459] are required on the claim form to submit
this category)

OR

CPT II 3266F: Hepatitis C genotype testing documented as performed prior to initiation of
antiviral treatment for hepatitis C
AND
G8459: Clinician documented that patient is receiving antiviral treatment for Hepatitis C

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If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8458] is required on the claim form to submit this category)
G8458: Clinician documented that patient is not an eligible candidate for genotype testing;
patient not receiving antiviral treatment for Hepatitis C
OR

Genotype Testing not Performed, Reason not Specified
(One CPT II code & one G-code [3266F-8P & G8459] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 3266F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3266F with 8P: Hepatitis C genotype testing was not documented as performed prior
to initiation of antiviral treatment for Hepatitis C, reason not otherwise specified
AND
G8459: Clinician documented that patient is receiving antiviral treatment for Hepatitis C

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving
antiviral treatment
Denominator Coding:
An ICD-9 diagnosis code for chronic hepatitis C and a CPT E/M service code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.54
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
To guide treatment decisions regarding duration of therapy and likelihood of response. There are 6
HCV genotypes and more than 50 subtypes. These genotypes differ by as much as 31 to 34
percent in their nucleotide sequences, whereas subtypes differ by 20 to 23 percent based on fulllength genomic sequence comparisons. Genotype determinations influence treatment decisions.
Patients with genotypes 2 or 3 have better response rates to re-treatment than those with genotype
1. (NIH)
CLINICAL RECOMMENDATION STATEMENTS:
HCV genotype should be determined in all HCV-infected persons prior to treatment in order to
determine the duration of therapy and likelihood of response (Grade I). (AASLD)
Information on the genotype of the virus is important to guide treatment decisions. Genotype 1,
most commonly found in the United States, is less amenable to treatment than genotypes 2 or 3.
(NIH)

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All candidates for antiviral therapy should be tested for HCV RNA with a quantitative amplification
assay and should be tested for HCV genotype. (AGA)

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Measure #86: Consideration for Antiviral Therapy in HCV Patients
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who were
considered for peginterferon and ribavirin therapy within the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients who were considered for peginterferon and ribavirin therapy within the 12 month reporting
period
Numerator Coding:
Peginterferon and Ribavirin Therapy Considered or Prescribed
CPT II 4152F: Documentation that combination peginterferon and ribavirin therapy
considered
OR
CPT II 4153F: Combination peginterferon and ribavirin therapy prescribed
OR

Peginterferon and Ribavirin Therapy not Considered or Prescribed, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4152F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Combination peginterferon and ribavirin therapy was not considered or prescribed,
reason not otherwise specified

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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C
Denominator Coding:
An ICD-9 diagnosis code for chronic hepatitis C and a CPT E/M service code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.54
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Assure that antiviral therapy is considered for all patients with confirmed Hepatitis C.
The current standard of care for the treatment of previously untreated patients with chronic
hepatitis C is combination pegylated interferon (PEG-IFN) alfa by subcutaneous injection once a
week and oral ribavirin daily. For patients with contraindications to ribavirin but who have
indications for antiviral therapy, PEG-IFN represents the best available treatment. (AGA)
Current contraindications to therapy include decompensated cirrhosis, pregnancy, uncontrolled
depression or severe mental illness, active substance abuse in the absence of concurrent
participation in a drug treatment program, advanced cardiac or pulmonary disease, severe
cytopenias, poorly controlled diabetes, retinopathy, seizure disorders, immunosuppressive
treatment, autoimmune diseases, or other inadequately controlled comorbid conditions.(AGA)
CLINICAL RECOMMENDATION STATEMENTS:
The treatment of choice is peginterferon plus ribavirin (Grade I). (AASLD)
The current standard of care for the treatment of previously untreated patients with chronic
hepatitis C is combination pegylated interferon (PEG-IFN) alfa by subcutaneous injection once a
week and oral ribavirin daily. For patients with contraindications to ribavirin but who have
indications for antiviral therapy, PEG-IFN represents the best available treatment. (Category
I)(AGA summ) Current contraindications to therapy include decompensated cirrhosis, pregnancy,
uncontrolled depression or severe mental illness, active substance abuse in the absence of
concurrent participation in a drug treatment program, advanced cardiac or pulmonary disease,
severe cytopenias, poorly controlled diabetes, retinopathy, seizure disorders, immunosuppressive
treatment, autoimmune diseases, or other inadequately controlled comorbid conditions (Category
I). (AGA)
Combination therapy results in better treatment responses than monotherapy, but the highest
response rates have been achieved with pegylated interferon in combination with ribavirin. (NIH)

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Measure #87: HCV RNA Testing at Week 12 of Therapy
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of chronic hepatitis C who are
receiving antiviral treatment for whom quantitative HCV RNA testing was performed at 12 weeks
from the initiation of antiviral treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
This measure is reported using CPT Category II codes and/or G-codes:
ICD-9 diagnosis codes, CPT E/M service codes and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
and/or G-codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 2Ppatient reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients for whom quantitative HCV RNA testing was performed at 12 weeks from the initiation of
antiviral treatment
Definition: Patients for whom testing was performed between 11-13 weeks from the
initiation of antiviral treatment will meet the numerator for this measure.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Hepatitis C Quantitative RNA Testing at 12 weeks
(One CPT II code & one G-code [3220F & G8461] are required on the claim form to submit
this category)
CPT II 3220F: Hepatitis C quantitative RNA testing documented as performed at 12 weeks
from initiation of antiviral treatment
AND
G8461: Patient receiving antiviral treatment for Hepatitis C

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OR

Hepatitis C Quantitative RNA Testing not Performed at 12 Weeks
(One CPT II code & one G-code [3220F-xP & G8461] are required on the claim form to
submit this category)
Append a modifier (1P or 2P) to CPT Category II code 3220F to report documented
circumstances that appropriately exclude patients from the denominator.
• 3220F with 1P: Documentation of medical reason(s) for not performing quantitative
HCV RNA at 12 weeks from initiation of antiviral treatment
• 3220F with 2P: Documentation of patient reason(s) for not performing quantitative
HCV RNA at 12 weeks from initiation of antiviral treatment
AND
G8461: Patient receiving antiviral treatment for Hepatitis C
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8460] is required on the claim form to submit this category)
G8460: Clinician documented that patient is not an eligible candidate for quantitative RNA
testing at week 12; patient not receiving antiviral treatment for Hepatitis C

OR

Hepatitis C Quantitative RNA Testing not Performed at 12 Weeks, Reason not
Specified
(One CPT II code & one G-code [3220F-8P & G8461] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 3220F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3220F with 8P: Hepatitis C quantitative RNA testing was not documented as
performed at 12 weeks from initiation of antiviral treatment, reason not otherwise
specified
AND
G8461: Patient receiving antiviral treatment for Hepatitis C

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of chronic hepatitis C who are receiving
antiviral treatment

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Denominator Coding:
An ICD-9 diagnosis code for chronic hepatitis C and a CPT E/M service code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.54
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Monitor effectiveness of antiviral therapy. An early virologic response (EVR), during the first 12
weeks of therapy, is a valuable clinical milestone. In the absence of an EVR, the likelihood of an
SVR is 0–3%. If the only goal of therapy is to achieve an SVR, therapy can be discontinued after
12 weeks if an EVR is not achieved. Potentially, histologic benefit can accrue even in the absence
of an SVR; therefore, some authorities treat beyond 12 weeks even in patients who have not
achieved an EVR. For documentation of a virologic response at the end of therapy (end-oftreatment response) or an SVR ≥ 6 months after completing therapy, a more sensitive quantitative
assay with a lower limit of ≤ 50 IU/mL, if available, or a qualitative HCV RNA assay is
recommended.
CLINICAL RECOMMENDATION STATEMENTS:
Baseline and 12-week monitoring of HCV RNA levels should be performed with the same
quantitative amplification assay. An early virologic response (EVR), defined as a ≥ 2-log10
reduction in HCV RNA levels during the first 12 weeks of therapy, is a valuable clinical milestone
(Category I). (AGA)
Clinical and virologic monitoring during therapy should be conducted at intervals ranging from once
a month to once every 3 months. Frequent hematologic monitoring is necessary to identify marked
anemia, neutropenia, and thrombocytopenia; monitoring of thyroid stimulating hormone level is
indicated to identify hypothyroidism or hyperthyroidism (Category I). (AGA)

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Measure #88: Hepatitis A and B Vaccination in Patients with HCV
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who were
recommended to receive or who have received hepatitis A vaccination or who have documented
immunity to hepatitis A AND who were recommended to receive or have received hepatitis B
vaccination or who have documented immunity to hepatitis B
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II codes OR the CPT Category II codes with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were recommended to receive or who have received hepatitis A vaccination or who
have documented immunity to hepatitis A AND who were recommended to receive or who have
received hepatitis B vaccination or who have documented immunity to hepatitis B
Numerator Instructions: Two CPT II codes are required for successful reporting.
Report one code for Hepatitis A Vaccine series and one code for Hepatitis B Vaccine
series

OR

Hepatitis A Numerator Coding:
Hepatitis A Vaccine Recommended or Previously Received or Patient Has
Documented Immunity
CPT II 4154F: Hepatitis A vaccine series recommended
OR
CPT II 4155F: Hepatitis A vaccine series previously received
OR
CPT II 3215F: Patient has documented immunity to Hepatitis A

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OR

Hepatitis A Vaccine not Recommended for Medical Reasons
Append a modifier (1P) to CPT Category II code 4154F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not recommending or administering
hepatitis A vaccine series
Hepatitis A Vaccine not Recommended, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4154F to report circumstances
when an action described in a measure’s numerator is not performed and the reason is not
otherwise specified.
• 8P: Hepatitis A Vaccine not recommended, reason not otherwise specified

AND

OR

OR

Hepatitis B Numerator Coding:
Hepatitis B Vaccine Recommended or Previously Received or Patient Has
Documented Immunity
CPT II 4156F: Hepatitis B vaccine series recommended
OR
CPT II 4157F: Hepatitis B vaccine series previously received
OR
CPT II 3216F: Patient has documented immunity to Hepatitis B
Hepatitis B Vaccine not Recommended for Medical Reasons
Append a modifier (1P) to CPT Category II code 4156F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not recommending or administering
hepatitis B vaccine series
Hepatitis B Vaccine not Recommended, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4156F to report circumstances
when an action described in a measure’s numerator is not performed and the reason is not
otherwise specified.
• 8P: Hepatitis B Vaccine not recommended, reason not otherwise specified

DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C
Denominator Coding:
An ICD-9 diagnosis code for hepatitis C and a CPT service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 070.51, 070.54, 070.70
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
Assure that hepatitis A and hepatitis B vaccinations are recommended/received except for cases of
documented medical reasons. These vaccinations decrease the potential for a patient acquiring for
hepatitis A and hepatitis B which would contribute to further liver damage.
CLINICAL RECOMMENDATION STATEMENTS:
All patients with chronic hepatitis C should be vaccinated against hepatitis A, and seronegative
persons with risk factors for hepatitis B virus (HBV) should be vaccinated against hepatitis B. (NIH)
Persons in whom the diagnosis of hepatitis C is established are candidates for hepatitis A and
hepatitis B vaccines. (AGA)

204

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Measure #89: Counseling Patients with HCV Regarding Use of Alcohol
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of hepatitis C who received
education regarding the risk of alcohol consumption at least once within the 12-month reporting
period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with a
diagnosis of hepatitis C seen during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients who received education regarding the risk of alcohol consumption at least once within the
12 month reporting period

OR

Numerator Coding:
Education Regarding Risk of Alcohol Consumption
CPT II 4158F: Patient education regarding risk of alcohol consumption performed
Education Regarding Risk of Alcohol Consumption not Performed, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4158F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Patient education regarding risk of alcohol consumption not performed, reason not
otherwise specified

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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of hepatitis C
Denominator Coding:
An ICD-9 diagnosis code for hepatitis C and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.51, 070.54, 070.70
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Minimize progression of liver disease. Higher levels of alcohol promote the development of
progressive liver disease, with strong evidence for the detrimental effects of 30 g/day in men
(~ equivalent to 2 beers, 2 glasses of wine, or 2 mixed drinks) and 20 g/day in women. Lower
amounts of alcohol also may increase the risk of liver damage associated with HCV (NIH)
CLINICAL RECOMMENDATION STATEMENTS:
Higher levels of alcohol use play an important role in promoting the development of progressive
liver disease, with strong evidence for the detrimental effects of 30 g/day in men (~ equivalent to 2
beers, 2 glasses of wine, or 2 mixed drinks) and 20 g/day in women. Lower amounts of alcohol
also may increase the risk of liver damage associated with HCV. (NIH)
Abstinence should be recommended before and during antiviral treatment in alcoholic persons, and
treatment of alcohol abuse should be linked with efforts to treat hepatitis C in alcoholic patients. A
safe level of alcohol consumption in patients with hepatitis C has not been established (Category II1b). (AGA)

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Measure #90 Counseling of Patients Regarding Use of Contraception Prior to Starting
Antiviral Therapy
DESCRIPTION:
Percentage of female patients aged 18 through 44 years and all men aged 18 years and older with
a diagnosis of chronic hepatitis C who are receiving antiviral treatment who were counseled
regarding contraception prior to the initiation of treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with a
diagnosis of chronic hepatitis C seen during the reporting period. This measure is intended to
reflect the quality of services provided for patients with chronic hepatitis C who are receiving
antiviral treatment. This measure may be reported by clinicians who perform the quality actions
described in the measure based on the services provided and the measure-specific denominator
coding.
This measure is reported using CPT Category II codes and/or G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
and/or G-codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 8Preasons not otherwise specified.
NUMERATOR:
Patients who were counseled regarding contraception prior to the initiation of treatment
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Education Regarding Contraception Received
(One CPT II code & one G-code [4159F & G8463] are required on the claim form to submit
this category)
CPT II 4159F: Counseling regarding contraception received prior to initiation of antiviral
treatment
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
OR

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Education Regarding Contraception not Received for Medical Reason
(One CPT II code & one G-code [4159F-1P & G8463] are required on the claim form to
submit this category)
Append a modifier (1P) to CPT Category II code 4159F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4159 with 1P: Documentation of medical reason(s) for not counseling patient
regarding contraception
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented
OR
If patient is not eligible for this measure because patient is not receiving antiviral
treatment, report:
(One G-code [G8462] is required on the claim form to submit this category)
G8462: Clinician documented that patient is not an eligible candidate for counseling
regarding contraception prior to antiviral treatment; patient not receiving antiviral treatment
for Hepatitis C
OR

Education Regarding Contraception not Received, Reason not Specified
(One CPT II code & one G-code [4159F-8P & G8463] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 4159F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4159F with 8P: Counseling regarding contraception not received prior to initiation of
antiviral treatment, reason not otherwise specified
AND
G8463: Patient receiving antiviral treatment for Hepatitis C documented

DENOMINATOR:
All women aged 18 through 44 years and all men aged 18 years and older with a diagnosis of
chronic hepatitis C who are receiving antiviral treatment
Denominator Coding:
An ICD-9 diagnosis code for chronic hepatitis C and a CPT E/M service code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 070.54
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
Ribavirin is contraindicated in pregnancy. Therefore, counseling regarding strict precautions and
contraception in women of childbearing age and their sexual partners and in HCV-infected men
with female partners of childbearing age needs to be provided to those receiving treatment for
chronic hepatitis C prior to the initiation of treatment. Although this measure is only captures data
related to counseling prior to therapy it should be subsequently re-enforced during treatment and
for a period of 6 months after treatment.
CLINICAL RECOMMENDATION STATEMENTS:
Because of the concern of birth defects from the use of ribavirin, it is imperative that persons who
receive the drug use strict contraception methods both during treatment and for a period of 6
months after treatment. (AASLD)
Ribavirin is contraindicated in pregnancy, necessitating strict precautions and contraception in
women of childbearing age and their sexual partners and in HCV-infected men with female
partners of childbearing age. (AGA)

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Measure #91: Acute Otitis Externa (AOE): Topical Therapy
DESCRIPTION:
Percentage of patients aged 2 years and older with a diagnosis of AOE who were prescribed
topical preparations
INSTRUCTIONS:
This measure is to be reported once for each occurrence of AOE during the reporting period. Each
unique occurrence is defined as a 30-day period from onset of AOE. Claims data will be analyzed
to determine unique occurrences. If multiple claims are submitted within that 30-day period, only
one instance of reporting will be counted. This measure may be reported by clinicians who perform
the quality actions described in the measure based on the services provided and the measurespecific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT E/M service
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons
not otherwise specified.
NUMERATOR:
Patients who were prescribed topical preparations

OR

OR

Numerator Coding:
Topical Preparations (including OTC) for Acute Otitis Externa (AOE) Prescribed
CPT II 4130F: Topical preparations (including OTC) prescribed for acute otitis externa
Topical Preparations (including OTC) for Acute Otitis Externa (AOE) not Prescribed
for Medical Reasons or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 4130F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing topical preparations
(including OTC) for acute otitis externa
• 2P: Documentation of patient reason(s) for not prescribing topical preparations
(including OTC) for acute otitis externa

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Topical Preparations (including OTC) for Acute Otitis Externa (AOE) not Prescribed,
Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4130F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Topical preparations (including OTC) for acute otitis externa (AOE) not prescribed,
reason not otherwise specified
DENOMINATOR:
All patients aged 2 years and older with a diagnosis of AOE
Denominator Coding:
An ICD-9 diagnosis code for AOE and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 380.10, 380.11, 380.12, 380.13, 380.22
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Topical preparations should be used to treat AOE as they are active against the most common
bacterial pathogens in AOE, Pseudomonas aeruginosa and Staphylococcus aureus. Topical
preparations have demonstrated efficacy in the treatment of AOE with resolution in about 65-90%
of patients.
CLINICAL RECOMMENDATION STATEMENTS:
Clinicians should use topical preparations for initial therapy of diffuse, uncomplicated AOE.
(Recommendation based on randomized controlled trials with minor limitations and a
preponderance of benefit over harm. [Aggregate evidence quality – Grade B]) (AAO-HNSF)

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Measure #92: Acute Otitis Externa (AOE): Pain Assessment
DESCRIPTION:
Percentage of patient visits for those patients aged 2 years and older with a diagnosis of AOE with
assessment for auricular or periauricular pain
INSTRUCTIONS:
This measure is to be reported at each visit for patients with AOE during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT E/M service
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patient visits with assessment for auricular or periauricular pain
Numerator Coding:
Auricular or Periauricular Pain Assessed
CPT II 1116F: Auricular or periauricular pain assessed
OR

OR

Auricular or Periauricular Pain not Assessed for Medical Reasons
Append a modifier (1P) to CPT Category II code 1116F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not assessing auricular or periauricular
pain
Auricular or Periauricular Pain not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1116F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Auricular or periauricular pain not assessed, reason not otherwise specified

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DENOMINATOR:
All patient visits for those patients aged 2 years and older with a diagnosis of AOE
Denominator Coding:
An ICD-9 diagnosis code for AOE and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 380.10, 380.11, 380.12, 380.13, 380.22
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Pain relief is a major goal in the management of AOE. Frequent use of analgesics is often
necessary to permit patients to achieve comfort, rest, and to resume normal activities. Ongoing
assessment of the severity of discomfort is essential for proper management.
CLINICAL RECOMMENDATION STATEMENTS:
The management of diffuse AOE should include an assessment of pain. The clinician should
recommend analgesic treatment based on the severity of pain. (Strong recommendation based on
well-designed randomized trials with a preponderance of benefit over harm. [Aggregate evidence
quality – Grade B]) (AAO-HNSF)

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Measure #93: Acute Otitis Externa (AOE): Systemic Antimicrobial Therapy – Avoidance of
Inappropriate Use
DESCRIPTION:
Percentage of patients aged 2 years and older with a diagnosis of AOE who were not prescribed
systemic antimicrobial therapy
INSTRUCTIONS:
This measure is to be reported once for each occurrence of AOE during the reporting period. Each
unique occurrence is defined as a 30-day period from onset of AOE. Claims data will be analyzed
to determine unique occurrences. If multiple claims are submitted within that 30-day period, only
one instance of reporting will be counted. This measure may be reported by clinicians who perform
the quality actions described in the measure based on the services provided and the measurespecific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT E/M service
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifier allowed for this measure is: 1P- medical reasons.
NUMERATOR:
Patients who were not prescribed systemic antimicrobial therapy
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom systemic antimicrobial therapy was not prescribed over the number of
patients in the denominator (patients aged 2 years and older with acute otitis externa). A
higher score indicates appropriate treatment of patients with AOE (e.g., the proportion for
whom systemic antimicrobials were not prescribed).

OR

OR

Numerator Coding:
Systemic Antimicrobial Therapy not Prescribed
CPT II 4132F: Systemic antimicrobial therapy not prescribed
Systemic Antimicrobial Therapy Prescribed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4131F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for prescribing systemic antimicrobial therapy
Systemic Antimicrobial Therapy Prescribed
CPT II 4131F: Systemic antimicrobial therapy prescribed

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DENOMINATOR:
All patients aged 2 years and older with a diagnosis of AOE
Denominator Coding:
An ICD-9 diagnosis code for AOE and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 380.10, 380.11, 380.12, 380.13, 380.22
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Despite their limited utility, many patients with AOE receive systemic antimicrobial therapy, often in
addition to topical therapy. “There are no data on the efficacy of systemic therapy with the use of
appropriate antibacterials and stratified by severity of the infection. Moreover, orally administered
antibiotics have significant adverse effects that include rashes, vomiting, diarrhea, allergic
reactions, altered nasopharyngeal flora, and development of bacterial resistance.” The use of
systemic antimicrobial therapy to treat AOE should be limited only to those clinical situations in
which it is indicated.
CLINICAL RECOMMENDATION STATEMENTS:
Systemic antimicrobial therapy should not be used unless there is extension outside the ear canal
or the presence of specific host factors that would indicate a need for systemic therapy.
(Recommendation based on randomized controlled trials with minor limitations and a
preponderance of benefit over harm. [Aggregate evidence quality – Grade B]) (AAO-HNSF)

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Measure #94: Otitis Media with Effusion (OME): Diagnostic Evaluation – Assessment of
Tympanic Membrane Mobility
DESCRIPTION:
Percentage of patient visits for those patients aged 2 months through 12 years with a diagnosis of
OME with assessment of tympanic membrane mobility with pneumatic otoscopy or tympanometry
INSTRUCTIONS:
This measure is to be reported at each visit for children with OME during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT E/M service
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons
not otherwise specified.
NUMERATOR:
Patient visits with assessment of tympanic membrane mobility with pneumatic otoscopy or
tympanometry

OR

Numerator Coding:
Tympanic Membrane Mobility Assessed
CPT II 2035F: Tympanic membrane mobility assessed with pneumatic otoscopy or
tympanometry
Tympanic Membrane Mobility not Assessed for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 2035F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not assessing tympanic membrane
mobility with pneumatic otoscopy or tympanometry
• 2P: Documentation of patient reason(s) for not assessing tympanic membrane mobility
with pneumatic otoscopy or tympanometry

OR

Tympanic Membrane Mobility not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2035F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Tympanic membrane mobility not assessed with pneumatic otoscopy or
tympanometry, reason not otherwise specified

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DENOMINATOR:
All patient visits for those patients aged 2 months through 12 years with a diagnosis of OME
Denominator Coding:
An ICD-9 diagnosis code for OME and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 381.10, 381.19, 381.20, 381.29, 381.3, 381.4
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Correctly diagnosing middle ear effusion is essential for proper management. OME is often
characterized by a cloudy tympanic membrane with distinctly impaired mobility which can best be
determined with pneumatic otoscopy or tympanometry.
CLINICAL RECOMMENDATION STATEMENTS:
Clinicians should use pneumatic otoscopy as the primary diagnostic method for OME. OME should
be distinguished from AOM. (Strong Recommendation based on systematic review of cohort
studies and preponderance of benefit over harm. [Aggregate evidence quality – Grade A])
Tympanometry can be used to confirm the diagnosis of OME. (Option based on cohort studies and
a balance of benefit and harm. [Aggregate evidence quality – Grade B]) (AAFP/AAO-HNSF/AAP)

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Measure #95: Otitis Media with Effusion (OME): Hearing Testing
DESCRIPTION:
Percentage of patients aged 2 months through 12 years with a diagnosis of OME who received
tympanostomy tube insertion who had a hearing test performed within 6 months prior to
tympanostomy tube insertion
INSTRUCTIONS:
This measure is to be reported each time a tympanostomy tube insertion procedure is performed
during the reporting period for children. It is anticipated that clinicians who perform the
tympanostomy tube insertion for children 2 months through 12 years of age with a diagnosis of
OME will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT procedure codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 3P- system reasons, 8Preasons not otherwise specified.
NUMERATOR:
Patients who had a hearing test performed within 6 months prior to tympanostomy tube insertion

OR

OR

Numerator Coding:
Hearing Test Performed within 6 Months Prior to Tympanostomy Tube Insertion
CPT II 3230F: Documentation that hearing test was performed within 6 months prior to
tympanostomy tube insertion
Hearing Test not Performed within 6 Months Prior to Tympanostomy Tube Insertion
for Medical or System Reasons
Append a modifier (1P or 3P) to CPT Category II code 3230F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not performing hearing test within 6
months prior to tympanostomy tube insertion
• 3P: Documentation of system reason(s) for not performing hearing test within 6
months prior to tympanostomy tube insertion

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Hearing Test not Performed within 6 Months Prior to Tympanostomy Tube Insertion,
Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3230F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Hearing test not performed within 6 months prior to tympanostomy tube insertion,
reason not otherwise specified
DENOMINATOR:
All patients aged 2 months through 12 years with a diagnosis of OME who received tympanostomy
tube insertion
Denominator Coding:
An ICD-9 diagnosis code for OME and a CPT procedure code for tympanostomy tube
insertion are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 381.10, 381.19, 381.20, 381.29, 381.3, 381.4
AND
CPT procedure codes: 69433, 69436
RATIONALE:
OME is often accompanied by hearing loss which can impair early language acquisition, especially
in severe cases which often necessitate tympanostomy tube insertion. Therefore, it is imperative
that any patient for whom tympanostomy tube insertion is indicated have their hearing tested.
CLINICAL RECOMMENDATION STATEMENTS:
Hearing testing is recommended when OME persists for 3 months or longer, or at any time that
language delay, learning problems, or a significant hearing loss is suspected in a child with OME.
(Recommendation based on cohort studies and preponderance of benefit over risk. [Aggregate
evidence quality – Grade B and C]) (AAFP/AAO-HNSF/AAP)

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Measure #96: Otitis Media with Effusion (OME): Antihistamines or Decongestants –
Avoidance of Inappropriate Use
DESCRIPTION:
Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not
prescribed/recommended either antihistamines or decongestants
INSTRUCTIONS:
This measure is to be reported once for each occurrence of OME in children seen during the
reporting period. Each unique occurrence is defined as a 90-day period from onset of OME. Claims
data will be analyzed to determine unique occurrences. If multiple claims are submitted within that
90-day period, only one instance of reporting will be counted. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons.
NUMERATOR:
Patients who were not prescribed/recommended either antihistamines or decongestants
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom antihistamines or decongestants were neither prescribed nor
recommended over the number of patients in the denominator (patients aged 2 months
through 12 years with a diagnosis of OME). A higher score indicates appropriate treatment
of patients with OME (e.g., the proportion for whom antihistamines or decongestants were
neither prescribed nor recommended).
Numerator Coding:
Antihistamines or Decongestants not Prescribed or Recommended
CPT II 4134F: Antihistamines or decongestants neither prescribed nor recommended
OR

OR

Antihistamines or Decongestants Prescribed or Recommended for Medical Reasons
Append a modifier (1P) to CPT Category II code 4133F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for prescribing or recommending
antihistamines or decongestants

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Antihistamines or Decongestants Prescribed or Recommended
CPT II 4133F: Antihistamines or decongestants prescribed or recommended
DENOMINATOR:
All patients aged 2 months through 12 years with a diagnosis of OME
Denominator Coding:
An ICD-9 diagnosis code for OME and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 381.10, 381.19, 381.20, 381.29, 381.3, 381.4
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
OME usually resolves spontaneously with indications for therapy only if the condition is persistent
and clinically significant benefits can be achieved. No data exists to support antihistamines and
decongestants in treating OME. As a result, physicians should not prescribe or recommend the
over-the-counter use of these medications.
CLINICAL RECOMMENDATION STATEMENTS:
Antihistamines and decongestants are ineffective for OME and are not recommended for
treatment. (Recommendation based on systematic review of randomized, controlled trials and
preponderance of harm over benefit. [Aggregate evidence quality – Grade A]) (AAFP/AAOHNSF/AAP)

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Measure #97: Otitis Media with Effusion (OME): Systemic Antimicrobials – Avoidance of
Inappropriate Use
DESCRIPTION:
Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not
prescribed systemic antimicrobials
INSTRUCTIONS:
This measure is to be reported once for each occurrence of OME in children seen during the
reporting period. Each unique occurrence is defined as a 90-day period from onset of OME. Claims
data will be analyzed to determine unique occurrences. If multiple claims are submitted within that
90-day period, only one instance of reporting will be counted. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons.
NUMERATOR:
Patients who were not prescribed systemic antimicrobials
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom systemic antimicrobial therapy was not prescribed over the number of
patients in the denominator (patients aged 2 months through 12 years with a diagnosis of
OME). A higher score indicates appropriate treatment of patients with OME (e.g., the
proportion for whom systemic antimicrobial therapy was not prescribed).
Systemic Antimicrobial Therapy not Prescribed
CPT II 4132F: Systemic antimicrobial therapy not prescribed
OR

OR

Systemic Antimicrobial Therapy Prescribed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4131F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for prescribing systemic antimicrobial therapy
Systemic Antimicrobial Therapy Prescribed
CPT II 4131F: Systemic antimicrobial therapy prescribed

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DENOMINATOR:
All patients aged 2 months through 12 years with a diagnosis of OME
Denominator Coding:
An ICD-9 diagnosis code for OME and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 381.10, 381.19, 381.20, 381.29, 381.3, 381.4
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
OME usually resolves spontaneously with indications for therapy only if the condition is persistent
and clinically significant benefits can be achieved. Antimicrobials have no proven long-term
effectiveness and have potential adverse effects.
CLINICAL RECOMMENDATION STATEMENTS:
Antimicrobials and corticosteroids do not have long-term efficacy and are not recommended for
routine management. (Recommendation based on systematic review of randomized, controlled
trials and preponderance of harm over benefit. [Aggregate evidence quality – Grade A])
(AAFP/AAO-HNSF/AAP)

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Measure #98: Otitis Media with Effusion (OME): Systemic Corticosteroids – Avoidance of
Inappropriate Use
DESCRIPTION:
Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not
prescribed systemic corticosteroids
INSTRUCTIONS:
This measure is to be reported once for each occurrence of OME in children seen during the
reporting period. Each unique occurrence is defined as a 90-day period from onset of OME. Claims
data will be analyzed to determine unique occurrences. If multiple claims are submitted within that
90-day period, only one instance of reporting will be counted. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons.
NUMERATOR:
Patients who were not prescribed systemic corticosteroids
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom systemic corticosteroids were neither prescribed nor recommended
over the number of patients in the denominator (patients aged 2 months through 12 years
with a diagnosis of OME). A higher score indicates appropriate treatment of patients with
OME (e.g., the proportion for whom systemic corticosteroids were not prescribed).
Systemic Corticosteroids not Prescribed
CPT II 4136F: Systemic corticosteroids not prescribed
OR

OR

Systemic Corticosteroids Prescribed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4135F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for prescribing systemic corticosteroids
Systemic Corticosteroids Prescribed
CPT II 4135F: Systemic corticosteroids prescribed

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DENOMINATOR:
All patients aged 2 months through 12 years with a diagnosis of OME
Denominator Coding:
An ICD-9 diagnosis code for OME and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 381.10, 381.19, 381.20, 381.29, 381.3, 381.4
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
OME usually resolves spontaneously with indications for therapy only if the condition is persistent
and clinically significant benefits can be achieved. Systemic steroids have no proven long-term
effectiveness and have potential adverse effects.
CLINICAL RECOMMENDATION STATEMENTS:
Antimicrobials and corticosteroids do not have long-term efficacy and are not recommended for
routine management. (Recommendation based on systematic review of randomized, controlled
trials and preponderance of harm over benefit. [Aggregate evidence quality – Grade A])
(AAFP/AAO-HNSF/AAP)

225

12/31/2007

Measure #99: Breast Cancer Patients who have a pT and pN Category and Histologic
Grade for Their Cancer
DESCRIPTION:
Percentage of breast cancer resection pathology reports that include the pT category (primary
tumor), the pN category (regional lymph nodes), and the histologic grade
INSTRUCTIONS:
This measure is to be reported each time a breast cancer resection surgical pathology examination
is performed during the reporting period for breast cancer patients. It is anticipated that clinicians
who examine breast tissue specimens following resection in a laboratory or institution will submit
this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Reports that include the pT category, the pN category and the histologic grade

OR

Numerator Coding:
pT Category, pN Category and Histologic Grade Documented
CPT II 3260F: pT category (primary tumor), pN category (regional lymph nodes), and
histologic grade documented in pathology report
pT Category, pN Category and Histologic Grade not Documented for Medical
Reasons
Append a modifier (1P) to CPT Category II code 3260F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not including pT category, pN category,
and histologic grade in the pathology report (e.g., re-excision without residual tumor;
non-carcinomas)

OR

pT Category, pN Category and Histologic Grade not Documented, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 3260F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.

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•

8P: pT category, pN category, and histologic grade were not documented in pathology
report, reason not otherwise specified

DENOMINATOR:
All breast cancer resection pathology reports (excluding biopsies)
Denominator Coding:
An ICD-9 diagnosis code for breast cancer and a CPT procedure code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9,
175.0, 175.9
AND
CPT procedure codes: 88307, 88309
RATIONALE:
Therapeutic decisions for breast cancer management are stage driven and cannot be made
without a complete set of pathology descriptors. Incomplete cancer resection pathology reports
may result in misclassification of patients, rework and delays, and suboptimal management. The
College of American Pathologists (CAP) has produced evidence-based checklists of essential
pathologic parameters that are recommended to be included in cancer resection pathology reports.
These checklists have been endorsed as a voluntary standard by National Quality Forum (NQF)
and are considered the reporting standard by the Commission on Cancer (CoC) of the American
College of Surgeons (ACS).
The CAP recently conducted a structured audit of breast cancer pathology report adequacy at 86
institutions. Overall, 35% of eligible reports were missing at least one of the ten CAPrecommended breast cancer elements. Cancer Care Ontario (CCO) conducted a similar study in
2005 and found that 25% of breast cancer pathology reports did not include all of the information
required by the CAP standards.
While the exact percentage of breast cancer resection pathology reports that are missing the pT
category, the pN category and the histologic grade is unknown, these are essential elements in
breast cancer treatment decisions and should be included in every pathology report when possible.
CLINICAL RECOMMENDATION STATEMENTS:
Patient management and treatment guidelines promote an organized approach to providing quality
care. The (American College of Surgeons Commission on Cancer) CoC requires that 90% of
pathology reports that include a cancer diagnosis contain the scientifically validated data elements
outlined in the surgical case summary checklist of the College of American Pathologists (CAP)
publication Reporting on Cancer Specimens. (ACSCoC)
All invasive breast carcinomas, with the exception of medullary carcinoma should be graded. The
grading system used must be specified in the report; the Nottingham combined histologic grade
(Elston-Ellis modification of Scarff-Bloom-Richardson grading system) is recommended. Within
each stage grouping there is a relation between histologic grade and outcome. (CAP)

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TNM staging information is included in factors proven to be of prognostic import and useful in
clinical patient management.(CAP)

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Measure #100: Colorectal Cancer Patients who have a pT and pN Category and Histologic
Grade for Their Cancer
DESCRIPTION:
Percentage of colon and rectum cancer resection pathology reports that include the pT category
(primary tumor), the pN category (regional lymph nodes) and the histologic grade
INSTRUCTIONS:
This measure is to be reported each time a colorectal cancer resection surgical pathology
examination is performed during the reporting period for colorectal cancer patients. It is anticipated
that clinicians who examine colorectal tissue specimens following resection in a laboratory or
institution will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Reports that include the pT category, the pN category and the histologic grade
Numerator Coding:
pT Category, pN Category and Histologic Grade Documented
CPT II 3260F: pT category (primary tumor), pN category (regional lymph nodes), and
histologic grade documented in pathology report
OR

OR

pT Category, pN Category and Histologic Grade not Documented for Medical
Reasons
Append a modifier (1P) to CPT Category II code 3260F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not including pT category, pN category
and histologic grade in the pathology report (e.g., non-carcinomas; anal canal)
pT Category, pN Category and Histologic Grade not Documented, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 3260F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: pT category, pN category and histologic grade were not documented in the
pathology report, reason not otherwise specified

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DENOMINATOR:
All colon and rectum cancer resection pathology reports
Denominator Coding:
An ICD-9 diagnosis code for colon or rectum cancer and a CPT procedure code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 153.0, 153.1, 153.2, 153.3, 153.4, 153.5, 153.6, 153.7, 153.8,
153.9, 154.0, 154.1, 154.8
AND
CPT procedure codes: 88309
RATIONALE:
Therapeutic decisions for colorectal cancer management are stage driven and cannot be made
without a complete set of pathology descriptors. Incomplete cancer resection pathology reports
may result in misclassification of patients, rework and delays, and suboptimal management. The
College of American Pathologists (CAP) has produced evidence-based checklists of essential
pathologic parameters that are recommended to be included in cancer resection pathology reports.
These checklists have been endorsed as a voluntary standard by National Quality Forum (NQF)
and are considered the reporting standard by the Commission on Cancer (CoC) of the American
College of Surgeons (ACS).
The CAP recently conducted a structured audit of colorectal cancer pathology report adequacy at
86 institutions. Overall, 34% of eligible reports were missing at least one of the ten CAPrecommended colorectal cancer elements. Cancer Care Ontario (CCO) conducted a similar study
in 2005 and found that 31% of colorectal cancer pathology reports did not include all of the
information required by the CAP standards.
While the exact percentage of colorectal cancer resection pathology reports that are missing the pT
category, the pN category and the histologic grade is unknown, these are essential elements in
colorectal cancer treatment decisions and should be included in every pathology report when
possible.
CLINICAL RECOMMENDATION STATEMENTS:
Patient management and treatment guidelines promote an organized approach to providing quality
care. The American College of Surgeons Committee on Cancer (CoC) requires that 90% of
pathology reports that include a cancer diagnosis contain the scientifically validated data elements
outlined in the surgical case summary checklist of the College of American Pathologists (CAP)
publication Reporting on Cancer Specimens.(ACSCoC)
Surgical resection is the primary therapy for most colorectal carcinomas, and the most important
prognostic indicators are related to the pathologic findings in the resection specimen. The anatomic
extent of disease is by far the most important prognostic factor in colorectal cancer. Pathologic
staging depends on pathologic documentation of the anatomic extent of disease, whether or not
the primary tumor has been completely removed. If a biopsied tumor is not resected for any reason

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(e.g., when technically unfeasible) and if the highest T and N categories or the M1 category of the
tumor can be confirmed microscopically, the criteria for pathologic classification and staging have
been satisfied without total removal of the primary cancer.(CAP)

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Measure #101: Appropriate Initial Evaluation of Patients with Prostate Cancer
DESCRIPTION:
Percentage of patients, regardless of age, with prostate cancer receiving interstitial prostate
brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR
cryotherapy with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T)
stage, AND Gleason score prior to initiation of treatment
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with prostate
cancer seen during the reporting period. It is anticipated that clinicians who perform interstitial
prostate brachytherapy, external beam radiotherapy to the prostate, radical prostatectomy, or
cryotherapy will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients with documented evaluation of prostate-specific antigen (PSA), AND primary tumor (T)
stage, AND Gleason score prior to initiation of treatment

OR

Numerator Coding:
Prostate-specific Antigen (PSA), Primary Tumor (T) Stage, and Gleason Score
Documented
CPT II 3268F: Prostate-specific antigen (PSA), AND primary tumor (T) stage, AND
Gleason score documented prior to initiation of treatment
Prostate-specific Antigen (PSA), Primary Tumor (T) Stage, and Gleason Score not
Documented for Medical Reasons
Append a modifier (1P) to CPT Category II code 3268F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not documenting prostate-specific antigen
(PSA), AND primary tumor (T) stage, AND Gleason score prior to initiation of treatment

OR

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Prostate-specific Antigen (PSA), Primary Tumor (T) Stage, and Gleason Score not
Documented, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3268F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Prostate-specific antigen (PSA), AND primary tumor (T) stage, AND Gleason
score not documented prior to initiation of treatment, reason not otherwise specified
DENOMINATOR:
All patients, regardless of age, with prostate cancer receiving interstitial prostate brachytherapy,
OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy
Denominator Coding:
An ICD-9 diagnosis code for prostate cancer and a CPT procedure code for patients
receiving interstitial prostate brachytherapy, external beam radiotherapy to the prostate,
radical prostatectomy, or cryotherapy are required to identify patients for denominator
inclusion.
ICD-9 diagnosis code: 185
AND
CPT E/M procedure codes: 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55873,
77411, 77412, 77413, 77414, 77416, 77418, 77427, 77776, 77777, 77778, 77784
RATIONALE:
The initial assessment of all prostate cancer patients should include the three evaluations required
in this measure.
CLINICAL RECOMMENDATION STATEMENTS:
Tumor characteristics, including PSA level and changes such as velocity and doubling time,
Gleason score, and tumor stage, are predictive of cancer outcomes. Using PSA, Gleason score,
and tumor stage, risk strata have been defined that are significantly associated with PSA
recurrence and cancer specific mortality. (AUA)
The combination of Gleason score, PSA level, and stage can effectively stratify patients into
categories associated with different probabilities of achieving a cure. In addition to considering the
probability of cure, the choice of initial treatment is highly influenced by estimated life expectancy,
comorbidities, potential therapy side effects, and patient preference. (NCCN)
(Category 2A)

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Measure #102: Inappropriate Use of Bone Scan for Staging Low-Risk Prostate Cancer
Patients
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low risk of
recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the
prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at
any time since diagnosis of prostate cancer
INSTRUCTIONS:
This measure is to be reported each time a patient with prostate cancer receives interstitial
prostate brachytherapy, external beam radiotherapy to the prostate, radical prostatectomy, or
cryotherapy procedure during the reporting period. It is anticipated that clinicians who perform the
listed procedures as specified in the denominator coding will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifiers allowed for this measure are: 1P- medical reasons, 3P- system reasons,
8P- reasons not otherwise specified.
NUMERATOR:
Patients who did not have a bone scan performed at any time since diagnosis of prostate cancer
Definitions:
Risk strata definitions:
• Low Risk: PSA ≤10 mg/dL; AND Gleason score 6 or less; AND clinical stage T1c or
T2a2
• Intermediate Risk: PSA >10 to 20 mg/dL; OR Gleason score 7; OR clinical stage T2b,
and not qualifying for high risk2
• High Risk: PSA > 20 mg/dL; OR Gleason score 8 to 10; OR clinical stage T2c or
greater; and not qualifying for very high risk2
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Bone Scan not Performed
(Two CPT II codes [3270F & 3271F] are required on the claim form to submit this
category)

OR

CPT II 3270F: Bone scan not performed prior to initiation of treatment nor at any time
since diagnosis of prostate cancer
AND
CPT II 3271F: Low risk of recurrence, prostate cancer
Bone Scan Performed for Medical or System Reasons
(Two CPT II codes [3269F-xP & 3271F] are required on the claim form to submit this
category)
Append a modifier (1P or 3P) to CPT Category II code 3269F to report documented
circumstances that appropriately exclude patients from the denominator.
• 3269F with 1P: Documentation of medical reason(s) for performing a bone scan
(including documented pain, salvage therapy, other medical reasons)
• 3269F with 3P: Documentation of system reason(s) for performing a bone scan
(including bone scan ordered by someone other than reporting physician)
AND
CPT II 3271F: Low risk of recurrence, prostate cancer
OR
If patient is not eligible for this measure because the risk of recurrence is
intermediate, high or not determined, report:
(One CPT II code [32xxF] is required on the claim form to submit this category)
Intermediate Risk of Recurrence
CPT II 3272F: Intermediate risk of recurrence, prostate cancer
OR
High Risk of Recurrence
CPT II 3273F: High risk of recurrence, prostate cancer
OR
Risk of Recurrence not Determined
CPT II 3274F: Prostate cancer risk of recurrence not determined or neither low,
intermediate nor high

OR

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Bone Scan Performed
(Two CPT II codes [3269F & 3271F] are required on the claim form to submit this
category)
CPT II 3269F: Bone scan performed prior to initiation of treatment or at any time since
diagnosis of prostate cancer
AND
CPT II 3271F: Low risk of recurrence, prostate cancer
DENOMINATOR:
All patients, regardless of age, with a diagnosis of prostate cancer at low risk of recurrence
receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR
radical prostatectomy, OR cryotherapy
Denominator Coding:
An ICD-9 diagnosis code for prostate cancer and a CPT procedure code for patients
receiving interstitial prostate brachytherapy, external beam radiotherapy to the prostate,
radical prostatectomy, or cryotherapy are required to identify patients for denominator
inclusion.
ICD-9 diagnosis code: 185
AND
CPT procedure codes: 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55873,
77411, 77412, 77413, 77414, 77416, 77418, 77427, 77776, 77777, 77778, 77784
RATIONALE:
A bone scan is generally not required for staging prostate cancer in men with a low risk of
recurrence. This measure is written as a negative measure so that the performance goal is 100%,
consistent with the other measures for this condition.
CLINICAL RECOMMENDATION STATEMENTS:
Routine use of a bone scan is not required for staging asymptomatic men with clinically localized
prostate cancer when their PSA is equal to or less than 20.0 ng/mL. (AUA)
Patients with a life expectancy > 5 years or symptomatic:
•
A bone scan is appropriate for T1 to T2 disease in the presence of a PSA greater than 20
ng/mL, Gleason score of 8 or higher, clinical stage of T3 to T4, or symptomatic disease.
•
Patients at higher risk of metastatic disease may undergo pelvic computed tomography (CT)
or magnetic resonance imaging (MRI) scanning with possible fine-needle aspiration of
enlarged lymph nodes or staging lymph node dissection. Nomograms or risk tables may be
used to identify patients with a higher likelihood of having metastatic disease. If the
nomogram indicates a probability of lymph node involvement greater than 20% or if the
patient is stage T3 or T4, this is recommended as a threshold for doing a staging CT scan or
MRI evaluation.
For all other patients, no additional imaging is required for staging. (NCCN) (Category 2A)

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Measure #103: Review of Treatment Options in Patients with Clinically Localized Prostate
Cancer
DESCRIPTION:
Percentage of patients, regardless of age, with clinically localized prostate cancer AND receiving
interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical
prostatectomy, OR cryotherapy who received counseling prior to initiation of treatment on, at a
minimum, the following treatment options for clinically localized disease: active surveillance, AND
interstitial prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with prostate
cancer receiving interstitial prostate brachytherapy, external beam radiotherapy to the prostate,
radical prostatectomy, or cryotherapy procedure during the reporting period. It is anticipated that
clinicians who perform interstitial prostate brachytherapy, external beam radiotherapy to the
prostate, radical prostatectomy, or cryotherapy will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code OR the CPT Category II code with the modifier.
The modifiers allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who received counseling on, at a minimum, the following treatment options for clinically
localized disease prior to initiation of treatment: active surveillance, AND interstitial prostate
brachytherapy, AND external beam radiotherapy, AND radical prostatectomy
Numerator Coding:
Counseling on Treatment Options for Clinically Localized Prostate Cancer Provided
CPT II 4163F: Patient counseling at a minimum on all of the following treatment options for
clinically localized prostate cancer: active surveillance, AND interstitial prostate
brachytherapy, AND external beam radiotherapy, AND radical prostatectomy, provided
prior to initiation of treatment
OR

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Counseling on Treatment Options for Clinically Localized Prostate Cancer not
Provided for Medical Reasons
Append a modifier (1P) to CPT Category II code 4163F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not counseling patient at a minimum on all
of the following treatment options for clinically localized prostate cancer: active
surveillance, AND interstitial prostate brachytherapy, AND external beam radiotherapy,
AND radical prostatectomy, (ie, salvage therapy)
OR

Counseling on Treatment Options for Clinically Localized Prostate Cancer not
Provided, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4163F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Patient was not provided counseling at a minimum on all of the following treatment
options for clinically localized prostate cancer: active surveillance, AND interstitial
prostate brachytherapy, AND external beam radiotherapy, AND radical prostatectomy,
reason not otherwise specified

DENOMINATOR:
All patients, regardless of age, with clinically localized prostate cancer AND receiving interstitial
prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy,
OR cryotherapy
Denominator Coding:
An ICD-9 diagnosis code for clinically localized prostate cancer without a secondary
malignant neoplasm diagnosis of a specified site (respiratory, digestive, and of other
specified sites) and a CPT procedure code for patients receiving interstitial prostate
brachytherapy, external beam radiotherapy to the prostate, radical prostatectomy, or
cryotherapy are required to identify patients for denominator inclusion.
ICD-9 diagnosis code: 185
WITHOUT
ICD-9 diagnosis codes: 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8,
198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, 198.81, 198.82, 198.89
AND
CPT procedure codes: 55810, 55812, 55815, 55840, 55842, 55845, 55866, 55873,
77261, 77262, 77263
RATIONALE:
To enable each prostate cancer patient with clinically localized disease to make an informed choice
among treatment options, he should receive counseling on at least the four interventions listed in
this measure. Additional treatment options may be offered, but fewer data are available to support
their effectiveness.

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CLINICAL RECOMMENDATION STATEMENTS:
A patient with clinically localized prostate cancer should be informed about the commonly accepted
initial interventions including, at a minimum, active surveillance, radiotherapy (external beam and
interstitial), and radical prostatectomy. A discussion of the estimates for benefits and harms of each
intervention should be offered to the patient. (AUA) (Standard)

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Measure #104: Adjuvant Hormonal Therapy for High-Risk Prostate Cancer Patients
DESCRIPTION:
Percentage of patients, regardless of age, with a diagnosis of prostate cancer at high risk of
recurrence receiving external beam radiotherapy to the prostate who were prescribed adjuvant
hormonal therapy (GnRH agonist or antagonist)
INSTRUCTIONS:
This measure is to be reported once per episode of radiation therapy for all patients with prostate
cancer who receive external beam radiotherapy to the prostate during the reporting period. Claims
data will be analyzed to determine unique episodes of radiation therapy. It is anticipated that
clinicians who perform external beam radiotherapy to the prostate will submit this measure.
This measure is reported using CPT Category II codes and/or G-codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes and/or G-codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT procedure codes and
the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The modifiers allowed for this measure are: 1P- medical reasons, 2Ppatient reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who were prescribed adjuvant hormonal therapy (GnRH [gonadotropin-releasing
hormone] agonist or antagonist)
Definitions:
Risk strata definitions:
• Low Risk: PSA ≤ 10 mg/dL; AND Gleason score 6 or less; AND clinical stage T1c or
T2a2
• Intermediate Risk: PSA > 10 to 20 mg/dL; OR Gleason score 7; OR clinical stage T2b,
and not qualifying for high risk2
• High Risk: PSA > 20 mg/dL; OR Gleason score 8 to 10; OR clinical stage T2c or
greater; and not qualifying for very high risk2
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.

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Numerator Coding:
Adjuvant Hormonal Therapy Prescribed/Administered
(One CPT II code & one G-code [4164F & G8465] are required on the claim form to submit
this category)
CPT II 4164F: Adjuvant (ie, in combination with external beam radiotherapy to the prostate
for prostate cancer) hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist or
antagonist) prescribed/administered
AND
G8465: High risk of recurrence of prostate cancer
OR

Adjuvant Hormonal Therapy not Prescribed/Administered for Medical or Patient
Reasons
(One CPT II code & one G-code [4164F-xP & G8465] are required on the claim form to
submit this category)
Append a modifier (1P or 2P) to CPT Category II code 4164F to report documented
circumstances that appropriately exclude patients from the denominator.
• 4164F with 1P: Documentation of medical reason(s) for not prescribing/administering
adjuvant (ie, in combination with external beam radiotherapy to the prostate for
prostate cancer) hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist
or antagonist)
• 4164F with 2P: Documentation of patient reason(s) for not prescribing/administering
adjuvant (ie, in combination with external beam radiotherapy to the prostate for
prostate cancer) hormonal therapy (GnRH [gonadotropin-releasing hormone] agonist
or antagonist)
AND
G8465: High risk of recurrence of prostate cancer
OR
If patient is not eligible for this measure because the risk of recurrence is low,
intermediate or not determined, report:
(One G-code [G8464] is required on the claim form to submit this category)

OR

G8464: Clinician documented that prostate cancer patient is not an eligible candidate for
adjuvant hormonal therapy; Low or intermediate risk of recurrence OR risk of recurrence
not determined

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Adjuvant Hormonal Therapy not Prescribed/Administered, Reason not Specified
(One CPT II code & one G-code [4164F-8P & G8465] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 4164F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4164F with 8P: Patients who were not prescribed/administered adjuvant (ie, in
combination with external beam radiotherapy for prostate cancer) hormonal therapy
(GnRH [gonadotropin-releasing hormone] agonist or antagonist), reason not otherwise
specified
AND
G8465: High risk of recurrence of prostate cancer
DENOMINATOR:
All patients, regardless of age, with a diagnosis of prostate cancer at high risk of recurrence
receiving external beam radiotherapy to the prostate
Denominator Coding:
An ICD-9 diagnosis code for prostate cancer and a CPT procedure code for patients
receiving external beam radiotherapy to the prostate are required to identify patients for
denominator inclusion.
ICD-9 diagnosis code: 185
AND
CPT procedure codes: 77407, 77408, 77409, 77411, 77412, 77413, 77414, 77416,
77418, 77427
RATIONALE:
If receiving external beam radiotherapy, prostate cancer patients with a high risk of recurrence
should also be prescribed hormonal therapy, which has been shown to increase the effectiveness
of the radiotherapy.
CLINICAL RECOMMENDATION STATEMENTS:
High risk patients who are considering specific treatment options should be informed of findings of
recent high quality clinical trials, including that: for those considering external beam radiotherapy,
use of hormonal therapy combined with conventional radiotherapy may prolong survival. (AUA)
(Standard)
Men with prostate cancer that is clinically localized stage T3a, with Gleason score of 8 to 10, or
PSA level greater than 20 ng/mL are categorized by the NCCN panel to be at high risk of
recurrence after definitive therapy. Note that patients with multiple adverse factors may be shifted
into the very high-risk category. Hormonal therapy (e.g., androgen ablation) plus external-beam RT
is recommended. (NCCN) (Category 1)

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Measure #105: Three-dimensional Radiotherapy for Patients with Prostate Cancer
DESCRIPTION:
Percentage of patients, regardless of age, with prostate cancer receiving external beam
radiotherapy to the prostate only (no metastases) who receive 3D-CRT or IMRT
INSTRUCTIONS:
This measure is to be reported each time an external beam radiotherapy to the prostate procedure
is performed during the reporting period for prostate cancer patients. It is anticipated that clinicians
who perform external beam radiotherapy to the prostate will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes and CPT procedure codes are used to identify patients who are included in
the measure’s denominator. CPT Category II codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate ICD-9 diagnosis codes, CPT procedure
codes, and the appropriate CPT Category II code(s) OR the CPT Category II code(s) with the
modifier. The modifier allowed for this measure is: 8P- reasons not otherwise specified. There are
no allowable performance exclusions for this measure.
NUMERATOR:
Patients who receive three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated
radiation therapy (IMRT)
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
3D-CRT or IMRT Received
(Two CPT II codes [4165F & 4200F] are required on the claim form to submit this
category)
CPT II 4165F: Three-dimensional conformal radiotherapy (3D-CRT) or intensity modulated
radiation therapy (IMRT) received
AND
CPT II 4200F: External beam radiotherapy to prostate only
OR

OR

If patient is not eligible for this measure because the 3D-CRT or IMRT is to region(s)
other than the prostate only, report:
(One CPT II code [4201F] is required on the claim form to submit this category)
CPT II 4201F: External beam radiotherapy for prostate cancer to region(s) other than
prostate only

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3D-CRT or IMRT not Received, Reason not Specified
(Two CPT II codes [4165F-8P & 4200F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 4165F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 4165F with 8P: Patients who did not receive three-dimensional conformal
radiotherapy (3D-CRT) or intensity modulated radiation therapy (IMRT), reason not
otherwise specified
AND
CPT II 4200F: External beam radiotherapy to prostate only
DENOMINATOR:
All patients, regardless of age, with prostate cancer receiving external beam radiotherapy to the
prostate only (no metastases)
Denominator Coding:
An ICD-9 diagnosis code for clinically localized prostate cancer without a secondary
malignant neoplasm diagnosis of a specified site (respiratory, digestive, and of other
specified sites) and a CPT procedure code for patients receiving external beam
radiotherapy to the prostate are required to identify patients for denominator inclusion.
ICD-9 diagnosis code: 185
WITHOUT
ICD-9 diagnosis codes: 197.0, 197.1, 197.2, 197.3, 197.4, 197.5, 197.6, 197.7, 197.8,
198.0, 198.1, 198.2, 198.3, 198.4, 198.5, 198.6, 198.7, 198.81, 198.82, 198.89
AND
CPT procedure codes: 77401, 77402, 77403, 77404, 77406, 77407, 77408, 77409,
77411, 77412, 77413, 77414, 77416, 77418, 77427
RATIONALE:
Current, computer-aided radiotherapy techniques improve the precision of the irradiation of
cancerous tissue and should be employed for all patients receiving external beam radiotherapy to
the prostate.
CLINICAL RECOMMENDATION STATEMENTS:
Three-dimensional CRT or intensity-modulated radiation therapy (IMRT) techniques should be
employed over conventional techniques. These techniques use computer software to integrate CT
images of the patients' internal anatomy in the treatment position, which allows the volume
receiving the high radiation dose to "conform" more exactly to the shape of the tumor. Threedimensional CRT has reduced both acute and late normal tissue toxicity in patients with prostate
cancer and allows higher cumulative doses to be delivered with a lower risk of late effects. (NCCN)
(Category 2A)

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Measure #106: Patients who have Major Depression Disorder who meet DSM IV Criteria
DESCRIPTION:
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major
depressive disorder (MDD) who met the DSM-IVTM criteria during the visit in which the new
diagnosis or recurrent episode was identified during the measurement period
INSTRUCTIONS:
This measure is to be reported once for each occurrence of a new diagnosis or recurrent episode
of MDD occurring prior to or during the reporting period. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding. An occurrence of a new diagnosis or recurrent
episode of MDD and DSM-IV™ diagnostic evaluation will be identified through the submission of
CPT II code 1040F and G-code G8467 for an individual patient. The CPT II code for diagnostic
evaluation should be reported once until remission occurs. At the time of remission, G-code G8466
should be reported to indicate the current occurrence of MDD has been resolved.
This measure is reported using CPT Category II codes and/or G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
and/or G-codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code AND/OR G-code OR the CPT Category II code with the
modifier AND G-code. The reporting modifier allowed for this measure is: 8P- reasons not
otherwise specified. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients with documented evidence that they met the DSM-IVTM criteria [At least 5 elements (must
include: 1) depressed mood or 2) loss of interest or pleasure) with symptom duration of 2 weeks or
longer] during the visit in which the new diagnosis or recurrent episode was identified.
Definitions:
• DSM-IV™ criteria includes presence of depressed mood, marked diminished
interest/pleasure, significant weight loss or weight gain, insomnia or hypersomnia,
psychomotor agitation or retardation, fatigue or loss of energy, feelings of
worthlessness, diminished ability to concentrate and recurrent suicidal ideation.
• Patient is considered to be in remission if he/she no longer meets DSM-IV™
criteria.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes. This includes patients whose
occurrences of MDD began prior to the reporting period and are still receiving treatment for
an occurrence of MDD.

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Numerator Coding:
DSM-IVTM Criteria for Major Depressive Disorder Documented
(One CPT II code & one G-code [1040F & G8467] are required on the claim form to submit
this category)
CPT II 1040F: DSM-IVTM criteria for major depressive disorder documented at the initial
evaluation
AND
G8467: Documentation of new diagnosis of initial or recurrent episode of major depressive
disorder
OR
OR

G8466: Report if patient is not eligible for this measure because their MDD is in
remission.
DSM-IVTM Criteria for Major Depressive Disorder not Documented, Reason not
Specified
(One CPT II code & one G-code [1040F-8P & G8467] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 1040F to allow the reporting of
circumstances when an action described in a measure’s numerator is not performed and
the reason is not otherwise specified.
• 1040F with 8P: DSM-IVTM criteria for major depressive disorder not documented at the
initial evaluation, reason not otherwise specified
AND
G8467: Documentation of new diagnosis of initial or recurrent episode of major depressive
disorder

DENOMINATOR:
All patients aged 18 years and older with a new diagnosis or recurrent episode of MDD
Denominator Coding:
An ICD-9 diagnosis code for major depressive disorder and a CPT E/M service code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32,
296.33, 296.34
AND
CPT E/M service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809,
90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862, 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Thorough assessment of depressive symptoms sets the basis for accurate diagnosis and treatment
of major depressive disorder.

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CLINICAL RECOMMENDATION STATEMENTS:
Successful treatment of patients with major depressive disorder is promoted by a thorough
assessment of the patient. (APA; Level I Recommendation)
Diagnostic criteria for 296.20-296.24- Major Depressive Disorder, Single Episode
A. Presence of a single Major Depressive Episode.
B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and
is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or
Psychotic Disorder Not Otherwise Specified.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.
Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like
episodes are substance or treatment induced or are due to the direct physiological effects
of a general medical condition. (DSM IV)
Diagnostic criteria for 296.30-296.34- Major Depressive Disorder, Recurrent
A. Presence of two or more Major Depressive Episodes.
Note: To be considered separate episodes, there must be an interval of at least
2 consecutive months in which criteria are not met for a Major Depressive Episode.
B. The Major Depressive Episodes are not better accounted for by Schizoaffective Disorder
and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional
Disorder, or Psychotic Disorder Not Otherwise Specified.
C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode.
Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like
episodes are substance or treatment induced or are due to the direct physiological effects
of a general medical condition. (DSM IV)
A. At least five of the following symptoms have been present during the same 2-week
period and represent a change from previous functioning; at least one of the symptoms is
either 1) depressed mood or 2) loss of interest or pleasure (do not include symptoms that
are clearly due to general medical condition or mood-incongruent delusions or
hallucinations).
1) Depressed mood most of the day, nearly every day as indicated by either subjective
report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day,
nearly every day (as indicated by either subjective account or observation made by
others)
3) Significant weight loss when not dieting or weight gain (e.g., a change of more than
5% body weight in a month), or decrease in appetite nearly every day
4) Insomnia or hypersomnia nearly every day
5) Psychomotor agitation or retardation nearly every day (observable by others, not
merely subjective feelings of restlessness or being slowed down)
6) Fatigue or loss of energy nearly every day
7) Feelings of worthlessness or excessive inappropriate guilt (which may be delusional)
nearly every day (not merely self-reproach or guilt about being sick)

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8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either
by subjective account or observed by others)
9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without
a specific plan, or a suicide attempt or specific plan for committing suicide
B. The symptoms do not meet criteria for a mixed episode
C. The symptoms cause clinically significant distress or impairment in social, occupational,
or other important areas of functioning
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a
drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)
E. The symptoms are not better accounted for by bereavement, i.e., after the loss of a
loved one, the symptoms persist for longer than 2 months or are characterized by marked
functional impairment, morbid preoccupation with worthlessness, suicidal ideation,
psychotic symptoms, or psychomotor retardation. (DSM-IV)

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Measure #107: Patients who have Major Depression Disorder who are Assessed for
Suicide Risks
DESCRIPTION:
Percentage of patients aged 18 years and older with a new diagnosis or recurrent episode of major
depressive disorder (MDD) who had a suicide risk assessment completed at each visit during the
measurement period
INSTRUCTIONS:
This measure is to be reported at each visit for a new diagnosis or recurrent episode of MDD, for
patients seen individually or as a group, during the reporting period. This measure may be reported
by clinicians who perform the quality actions described in the measure based on the services
provided and the measure-specific denominator coding. An occurrence of a new diagnosis or
recurrent episode of MDD will be identified through the submission of CPT II code 3093F for an
individual patient. The CPT II code for suicide risk assessment 3085F should be reported at each
visit with CPT II code 3093F until remission occurs. At the time of remission, CPT II code 3092F
should be reported to indicate the current occurrence of MDD has been resolved.
This measure is reported using CPT Category II codes
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II code(s)
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code(s) OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patients who had suicide risk assessment completed at each visit
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Suicide Risk Assessed
(Two CPT II codes [3085F & 3093F] are required on the claim form to submit this
category)

OR

CPT II 3085F: Suicide risk assessed
AND
CPT II 3093F: Documentation of new diagnosis of initial or recurrent episode of major
depressive disorder

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If patient is not eligible for this measure because MDD is in remission, report:
(One CPT II code [3092F] is required on the claim form to submit this category)
CPT II 3092F: Major depressive disorder, in remission
OR

Suicide Risk not Assessed, Reason not Specified
(Two CPT II codes [3085F-8P & 3093F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3085F to allow the reporting of
circumstances when an action described in a measure’s numerator is not performed and
the reason is not otherwise specified.
• 3085F with 8P: Suicide risk not assessed, reason not otherwise specified
AND
CPT II 3093F: Documentation of new diagnosis of initial or recurrent episode of major
depressive disorder

DENOMINATOR:
All patients aged 18 years and older with a new diagnosis or recurrent episode of MDD
Denominator Coding:
An ICD-9 diagnosis code for major depressive disorder and a CPT E/M service code are
required to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 296.20, 296.21, 296.22, 296.23, 296.24, 296.30, 296.31, 296.32,
296.33, 296.34
AND
CPT E/M service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809,
90810, 90811, 90812, 90813, 90814, 90815, 90845, 90862, 99201, 99202, 99203, 99204,
99205, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Research has shown that patients with major depressive disorder are at a high risk for suicide,
which makes this assessment an important aspect of care that should be assessed at each visit.
CLINICAL RECOMMENDATION STATEMENTS:
Successful treatment of patients with major depressive disorder is promoted by a thorough
assessment of the patient. (APA; Level I Recommendation)
Psychiatric management consists of a broad array of interventions and activities that should be
instituted by psychiatrists for all patients with major depressive disorder. (APA; Level I
Recommendation)
The components of an evaluation for suicide risk should include:
1) An assessment of the presence of suicidal or homicidal ideation, intent, or plans
2) Access to means for suicide and the lethality of those means
3) Presence of psychotic symptoms, command hallucinations, or severe anxiety

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4) Presence of alcohol or substance abuse
5) History of seriousness of previous attempts
6) Family history or recent exposure to suicide (APA)

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Measure #108: Disease Modifying Anti-Rheumatic Drug Therapy in Rheumatoid Arthritis
DESCRIPTION:
Percentage of patients aged 18 years and older who were diagnosed with rheumatoid arthritis and
were prescribed, dispensed, or administered at least one ambulatory prescription for a disease
modifying anti-rheumatic drug (DMARD)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. It is anticipated that clinicians who provide care for patients with a diagnosis of
rheumatoid arthritis will submit this measure.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes can be
used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier codes allowed for this measure are: 1P- medical reasons, 8P- reasons not otherwise
specified.
NUMERATOR:
Patients who were prescribed, dispensed, or administered at least one disease modifying antirheumatic drug (DMARD)
Definition: "Prescribed" includes patients who are currently receiving medication(s) that
follow the treatment plan recommended at an encounter during the reporting period, even
if the prescription for that medication was ordered prior to the encounter.
Numerator Coding:
DMARD Prescribed, Dispensed, or Administered
CPT II 4187F: Disease modifying anti-rheumatic drug therapy prescribed, dispensed, or
administered
OR

OR

DMARD not Prescribed, Dispensed, or Administered for Medical Reasons
Append a modifier (1P) to CPT Category II code 4187F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not prescribing, dispensing, or
administering disease modifying anti-rheumatic drug therapy

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DMARD not Prescribed, Dispensed, or Administered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 4187F to report circumstances
when the action described in the numerator is not performed and the reason is no
otherwise specified.
• 8P: Disease modifying anti-rheumatic drug therapy was not prescribed, dispensed, or
administered, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with a diagnosis of rheumatoid arthritis
Denominator Coding:
An ICD-9 diagnosis code for rheumatoid arthritis and a CPT E/M service code are required
to identify patients for denominator inclusion.
ICD-9 diagnosis codes: 714.0, 714.1, 714.2, 714.81
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99455,
99456
RATIONALE:
Arthritis and other rheumatic conditions comprise the leading cause of disability among adults in
the United States, and the cost of this public health burden is expected to increase as the U.S.
population ages. Rheumatoid arthritis (RA) affects 1 percent of the adult population. Although the
course of RA in individual patients is highly variable, most patients with persistent RA develop
progressive functional limitation and physical disability. In addition, there is excess mortality and
decreased survival among patients with persistent RA compared with the general population. While
the prevalence of RA is low, the associated costs are very high over the lifetime of the affected
person. Costs of RA amount to approximately 1 percent of the U.S. Gross National Product.
RA is a chronic autoimmune disorder often characterized by progressive joint destruction and
multi-system involvement. RA affects approximately 2.5 million Americans, disproportionately
women. There is no cure; consequently, the goal of treatment is to slow the progression of disease,
thereby delaying or preventing joint destruction, relieving pain and maintaining functional capacity.
RA pain is often most effectively managed in the long term by altering the natural history of the
active progressive disease with DMARDs, but analgesics and anti-inflammatory drugs also have an
important place in pain management.
CLINICAL RECOMMENDATION STATEMENTS:
RA should be treated as early as possible with DMARDs to control symptoms and delay disease
progression.
Good Practice Point: All patients with persistent inflammatory joint disease (> 6–8 weeks duration)
already receiving simple analgesics and NSAIDs should be considered for referral for specialist
rheumatology opinion and DMARD therapy, preferably within 12 weeks.
Early DMARD therapy in RA is important to maintain function and reduce later disability.
DMARD therapy should be sustained in inflammatory disease in order to maintain disease
suppression.

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American College of Rheumatology (ACR) Subcommittee on Rheumatoid Arthritis Guidelines:
Guidelines for the Management of Rheumatoid Arthritis. The majority of patients with newly
diagnosed RA should be started on DMARD therapy within three months of diagnosis. All patients
with RA are candidates for DMARD therapy. Although NSAIDs and glucocorticoids may alleviate
symptoms, joint damage may continue to occur and progress.
Initiation of DMARD therapy should not be delayed beyond three months for any patient with an
established diagnosis who, despite adequate treatment with NSAIDs, has ongoing joint pain,
significant morning stiffness or fatigue, active synovitis, persistent elevation of the ESR or CRP
level or radiographic joint damage. For any untreated patient with persistent synovitis and joint
damage, DMARD treatment should be started promptly to prevent or slow further damage.
(ACR: Wherever possible, guidelines are evidence-based. However, because significant gaps in
knowledge still exist, some recommendations are based on best practices and a consensus of the
committee.)
American College of Rheumatology Subcommittee of Rheumatoid Arthritis. Guidelines for the
Management of Rheumatoid Arthritis: 2002 Update. Arthritis Rheum. 2002;46:328-346.
Scottish Intercollegiate Guidelines Network: Management of Early Rheumatoid Arthritis.
There is clear evidence from placebo-controlled trials that DMARDs reduce symptoms in RA (as
measured by joint pain, swelling and tenderness, and duration and severity of morning stiffness).
DMARDs also improve global well being, as assessed by both patients and physicians. It is
becoming increasingly clear that DMARDs should be introduced as soon as possible. Protracted
benefit may be achieved in RA patients if appropriate DMARD therapy is introduced early.
Refer to Scottish Intercollegiate Guidelines Network. Management of Early Rheumatoid Arthritis,
2000.

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Measure #109: Patients with Osteoarthritis who have an Assessment of Their Pain and
Function
DESCRIPTION:
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis
(OA) with assessment for function and pain
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients with
osteoarthritis seen during the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
reporting modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no
allowable performance exclusions for this measure.
NUMERATOR:
Patient visits with assessment for level of function and pain documented
Numerator Coding:
Osteoarthritis Symptoms and Functional Status Assessed
CPT II 1006F: Osteoarthritis symptoms and functional status assessed (may include the
use of a standardized scale or the completion of an assessment questionnaire, such as an
SF-36, AAOS Hip & Knee Questionnaire)
OR

Osteoarthritis Symptoms and Functional Status not Assessed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 1006F to allow the reporting of
circumstances when an action described in a measure’s numerator is not performed and
the reason is not otherwise specified.
• 8P: Osteoarthritis symptoms and functional status not assessed, reason not otherwise
specified

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DENOMINATOR:
All patient visits for patients aged 21 years and older with a diagnosis of OA
Denominator Coding:
An ICD-9 diagnosis code for osteoarthritis and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 715.00, 715.04, 715.09, 715.10, 715.11, 715.12, 715.13, 715.14,
715.15, 715.16, 715.17, 715.18, 715.20, 715.21, 715.22, 715.23, 715.24, 715.25, 715.26,
715.27, 715.28, 715.30, 715.31, 715.32, 715.33, 715.34, 715.35, 715.36, 715.37, 715.38,
715.80, 715.89, 715.90, 715.91, 715.92, 715.93, 715.94, 715.95, 715.96, 715.97, 715.98
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Osteoarthritis can be a debilitating condition. An assessment of patient symptoms and functional
status is important as it serves as the basis for making treatment modifications, which in turn,
assists in improving the patient’s quality of life.
CLINICAL RECOMMENDATION STATEMENTS:
Because pain is a major cause of disability in people with arthritis, assessment of functional status
should be included in the pain assessment. When selecting a functional status measure,
consideration should be given to the cognitive-developmental abilities of the person, the type of
practice setting, the domains of function to be assessed, and the time and resources needed to
complete the assessment. (APS; B Recommendation)
Any persistent pain that has an impact on physical function, psychosocial function, or other aspects
of quality of life should be recognized as a significant problem. (AGA; IIA Recommendation)
Control of pain and maintenance of activity correlate well with satisfactory quality of life. (AAOS)

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Measure #110: Influenza Vaccination for Patients ≥ 50 Years Old
DESCRIPTION:
Percentage of patients aged 50 years and older who received an influenza immunization during the
flu season (September through February)
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. This measure is intended to determine whether or not all patients aged 50 years
and older received or had an order for influenza immunization during the flu season. There is no
diagnosis associated with this measure. This measure may be reported by clinicians who perform
the quality actions described in the measure based on the services provided and the measurespecific denominator coding.
This measure is reported using G-codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who received an influenza immunization during the flu season (September through
February)

OR

OR

Numerator Coding:
Influenza Immunization Administered
G8482: Influenza immunization was ordered or administered
Influenza Immunization not Administered for Documented Reasons
G8483: Influenza immunization was not ordered or administered for reasons documented
by clinician
Influenza Immunization not Administered, Reason not Specified
G8484: Influenza immunization was not ordered or administered, reason not specified

DENOMINATOR:
All patients aged 50 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
Influenza vaccination has shown to decrease hospitalizations for influenza, especially for those
with risk factors, however annual influenza vaccination rates remain low.
CLINICAL RECOMMENDATION STATEMENTS:
Annual influenza immunization is recommended for all groups who are at increased risk for
complications from influenza including persons aged ≥ 50 years. (CDC, USPSTF)

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Measure #111: Pneumonia Vaccination for Patients 65 Years and Older
DESCRIPTION:
Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. Performance for this
measure is not limited to the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on services provided and the measurespecific denominator coding.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who have ever received a pneumococcal vaccination

OR

OR

Numerator Coding:
Pneumonia Vaccination Administered or Previously Received
CPT II 4040F: Pneumococcal vaccine administered or previously received
Pneumonia Vaccination not Administered or Previously Received for Medical
Reasons
Append a modifier (1P) to CPT Category II code 4040F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for not administering or previously receiving
pneumococcal vaccination
Pneumonia Vaccination not Administered or Previously Received, Reason not
Specified
Append a reporting modifier (8P) to CPT Category II code 4040F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Pneumococcal vaccine was not administered or previously received, reason not
otherwise specified

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DENOMINATOR:
All patients 65 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M Codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214,
99215, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99324, 99325, 99326,
99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347,
99348, 99349, 99350, 99356, 99357
RATIONALE:
The elderly have a much higher mortality from community-acquired pneumonia due to increased
risk factors such as comorbidities, an increase in the number of medications taken and
weaknesses or disease of lung tissue. Pneumonia accounts for an estimated 20 percent of
nosocomial infections among the elderly, second only to urinary tract infections. The disease
burden is large for older adults and the potential for prevention is high. (Ely, E., 1997)
Drugs such as penicillin were once effective in treating these infections; but the disease has
become more resistant, making treatment of pneumococcal infections more difficult. This makes
prevention of the disease through vaccination even more important. (CDC. National Immunization
Program—Pneumococcal Disease., 2005)
CLINICAL RECOMMENDATION STATEMENTS:
The U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services recommends
pneumococcal vaccine for all immunocompetent individuals who are 65 and older or otherwise at
increased risk for pneumococcal disease. Routine revaccination is not recommended, but may be
appropriate in immunocompetent individuals at high risk for morbidity and mortality from
pneumococcal disease (e.g., persons ≥ 75 years of age or with severe chronic disease) who were
vaccinated more than five years previously. Medicare Part B fully covers the cost of the vaccine
and its administration every five years. (United States Preventive Services Task Force, 1998)
Pneumococcal infection is a common cause of illness and death in the elderly and persons with
certain underlying conditions. In 1998, an estimated 3,400 adults aged ≥ 65 years died as a result
of invasive pneumococcal disease. Pneumococcal infection accounts for more deaths than any
other vaccine-preventable bacterial disease. (CDC, 2002; Pneumococcal Pneumonia, NIAID Fact
Sheet, December 2004.)
One of the Healthy People 2010 objectives is to increase pneumococcal immunization levels for
the non-institutionalized, high-risk populations to at least 90 percent (objective no. 14.29). While
the percent of persons 65 years and older receiving the pneumococcal vaccine has increased, it
still remains considerably below the Health People 2010 objective. According to the National
Health Interview Survey (NHIS), which is used to track performance on year 2010 objectives, in
1998 only 46 percent of adults age 65 years and older report receiving the vaccine. The figure was
45 percent based on the 1997 Behavioral Risk Factor Surveillance System (BRFSS) survey.
(National Center for Health Statistics., 2005; CDC, 1997)

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A particular strength of this measure is that it provides an opportunity to compare performance
against national, state and/or regional benchmarks, which are collected through nationally
organized and administered surveys.
At the physician practice level where a patient survey may not be feasible, data collection on
pneumonia vaccination status through chart abstraction is a viable option.

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Measure #112: Screening Mammography
DESCRIPTION:
Percentage of women aged 40 through 69 years who had a mammogram to screen for breast
cancer within 24 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for female patients seen
during the reporting period. There is no diagnosis associated with this measure. Breast cancer
screening is to be performed at least once within 24 months prior to the date of service.
Performance for this measure is not limited to the reporting period. This measure may be reported
by clinicians who perform the quality actions described in the measure based on services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who had a mammogram at least once within 24 months
Numerator Coding:
Mammogram Performed
CPT II 3014F: Screening mammography results documented and reviewed
OR

OR

Mammogram not Performed for Medical Reasons
Append a modifier (1P) to the above CPT Category II code 3014F to report documented
circumstances that appropriately exclude patients from the denominator
• 1P: Documentation of medical reason(s) for not performing a mammogram (i.e.,
women who had a bilateral mastectomy or two unilateral mastectomies).
Mammogram not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3014F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Screening mammography results were not documented and reviewed, reason not
otherwise specified

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DENOMINATOR:
All female patients aged 40 through 69 years
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Breast cancer ranks as the second leading cause of death in women. For women 40 to 49 years of
age mammography can reduce mortality by 17 percent. (AMA, 2003)
CLINICAL RECOMMENDATION STATEMENT:
The U.S. Preventive Services Task Force (USPSTF) recommends screening mammography, with
or without clinical breast examination (CBE), every 1-2 years for women aged 40 and older.
(USPSTF, 2002)
•
•

•

The USPSTF found fair evidence that mammography screening every 12-33 months
significantly reduces mortality from breast cancer. Evidence is strongest for women aged
50-69, the age group generally included in screening trials. (USPSTF, 2002)
For women aged 40-49, the evidence that screening mammography reduces mortality
from breast cancer is weaker, and the absolute benefit of mammography is smaller, than it
is for older women. Most, but not all, studies indicate a mortality benefit for women
undergoing mammography at ages 40-49, but the delay in observed benefit in women
younger than 50 makes it difficult to determine the incremental benefit of beginning
screening at age 40 rather than at age 50. (USPSTF, 2002)
The absolute benefit is smaller because the incidence of breast cancer is lower among
women in their 40s than it is among older women. (USPSTF, 2002)

The USPSTF concluded that the evidence is also generalizable to women aged 70 and older (who
face a higher absolute risk for breast cancer) if their life expectancy is not compromised by
comorbid disease. The absolute probability of benefits of regular mammography increases along a
continuum with age, whereas the likelihood of harms from screening (false-positive results and
unnecessary anxiety, biopsies, and cost) diminishes from ages 40-70. The balance of benefits and
potential harms, therefore, grows more favorable as women age. The precise age at which the
potential benefits of mammography justify the possible harms is a subjective choice. (USPSTF,
2002)
American Cancer Society: Yearly Mammograms starting at age 40 and continuing for as long as a
woman is in good health. (Smith, 2003)
American College of Preventative Medicine (ACPM):
•

Low-risk women (no family history, familial cancer syndrome, or prior cancer). There is
inadequate evidence for or against mammography screening of women under the age of
50. Women between the ages of 50-69 should have annual or biennial, high-quality, two-

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•

view mammography. Women aged 70 and older should continue undergoing
mammography screening provided their health status permits breast cancer treatment.
(Ferrini, 1996)
Higher-risk women: Women with a family history of pre-menopausal breast cancer in a
first-degree relative or those with a history of breast and/or gynecologic cancer may
warrant more aggressive screening. Women with these histories often begin screening at
an earlier age, although there is no direct evidence of effectiveness to support this
practice. The future availability of genetic screening may define new recommendations for
screening high-risk women. (Ferrini, 1996)

The American Medical Association (AMA), the American College of Obstetricians and
Gynecologists (ACOG), and the American College of Radiology (ACR), all support screening with
mammography and CBE beginning at age 40. (AMA, 1999; ACOG, 2000; Feig, 1998)
The Canadian Task Force on Preventive Health Care (CTFPHC), and the American Academy of
Family Physicians (AAFP), recommends beginning mammography for average-risk women at age
50. (Canadian Task Force on the Periodic Health Examination, 1999; AAFP, 2005)
AAFP recommends that mammography in high-risk women begin at age 40, and recommends that
all women aged 40-49 be counseled about the risks and benefits of mammography before making
decisions about screening. (AAFP, 2005)

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Measure #113: Colorectal Cancer Screening
DESCRIPTION:
Percentage of patients aged 50 through 80 years who received the appropriate colorectal cancer
screening
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. Performance for this
measure is not limited to the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on services provided and the measurespecific denominator coding.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes, and the appropriate CPT
Category II code OR the CPT Category II code with the modifier. The modifiers allowed for this
measure are: 1P- medical reasons, 8P- reasons not otherwise specified.
NUMERATOR:
Patients who had at least one or more screenings for colorectal cancer during or prior to the
reporting period
Numerator Instructions: Patients are considered to have appropriate screening for
colorectal cancer if any of the following are documented:
• Fecal occult blood test (FOBT) during the reporting period
• Flexible sigmoidoscopy during the reporting period or the four years prior to the
• reporting period
• Double contrast barium enema (DCBE) or air contrast barium enema during the
reporting period or the four years prior to the reporting period
• Colonoscopy during the reporting period or the nine years prior to the reporting period
Numerator Coding:
Colorectal Cancer Screening
CPT II 3017F: Colorectal cancer screening results documented and reviewed
OR

Colorectal Cancer Screening not Performed for Medical Reasons
Append a modifier (1P) to CPT Category II code 3017F to report documented
circumstances that appropriately exclude patients from the denominator
• 1P: Documentation of medical reason(s) for not performing a colorectal cancer
screening

OR

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Colorectal Cancer Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3017F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Colorectal cancer screening results were not documented and reviewed, reason
not otherwise specified
DENOMINATOR:
All patients aged 50 through 80 years
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308,
99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337
RATIONALE:
Colorectal cancer is the second leading cause of cancer-related death in the United States. There
were an estimated 135,400 new cases and 56,700 deaths from the disease during 2001.
Colorectal cancer (CRC) places significant economic burden on the society as well with treatment
costs over $6.5 billion per year and, among malignancies, is second only to breast cancer at $6.6
billion per year (Schrag, 1999).
Colorectal cancer screening can detect pre-malignant polyps and early stage cancers. Unlike other
screening tests that only detect disease, colorectal cancer screening can guide removal of premalignant polyps, which in theory can prevent development of colon cancer. Four tests are
currently available for screening: fecal occult blood testing (FOBT), flexible sigmoidoscopy,
colonoscopy, and double contrast barium enema.
CLINICAL RECOMMENDATION STATEMENTS:
During the past decade, compelling evidence has accumulated that systematic screening of the
population can reduce mortality from colorectal cancer. Three randomized, controlled trials
demonstrated that fecal occult blood testing (FOBT), followed by complete diagnostic evaluation of
the colon for a positive test, reduced colorectal cancer mortality (Hardcastle et al., 1996; Mandel &
Oken, 1998; Kronborg; 1996). One of these randomized trials (Mandel et al., 1993) compared
annual FOBT screening to biennial FOBT screening, and found that annual screening resulted in
greater reduction in colorectal cancer mortality. Two case control studies have provided evidence
that sigmoidoscopy reduces colorectal cancer mortality (Selby et al., 1992; Newcomb et al., 1992).
Approximately 75% of all colorectal cancers arise sporadically (Stephenson et al., 1991). Part of
the effectiveness of colorectal cancer screening is mediated by the removal of the precursor
lesion—an adenomatous polyp (Vogtelstein et al., 1988). It has been shown that removal of polyps
in a population can reduce the incidence of colorectal cancer (Winawer, 1993). Colorectal
screening may also lower mortality by allowing detection of cancer at earlier stages, when
treatment is more effective (Kavanaugh, 1998).
Because of the accumulated evidence, broad consensus has emerged about the virtue of
screening individuals aged 50 years or older for colorectal cancer. In 1996, the U.S. Preventive

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Services Task Force (USPSTF) published guidelines that recommended screening all persons
aged 50 and older for colorectal cancer by annual FOBT or sigmoidoscopy (at unspecified
periodicity) or both (USPSTF, 1997). In February 1997, clinical practice recommendations were
issued by an interdisciplinary task force originally convened by the Agency for Health Care Policy
and Research (AHCPR; the agency has since been renamed the Agency for Healthcare Research
and Quality) and supported by a consortium of professional organizations including the American
Gastroenterological Association (Winawer, 1997). The American Cancer Society (ACS) has
recommended screening for colorectal cancer since 1980 and recently updated its guidelines in
January, 2002 (Smith et al., 2002). These updated guidelines recommend colorectal cancer
screening starting at age 50 for all persons at average risk of developing colorectal cancer using
one of five options for screening: (1) annual FOBT; (2) flexible sigmoidoscopy every 5 years; (3)
annual FOBT plus flexible sigmoidoscopy every 5 years; (4) double contrast barium enema
(DCBE) every five years; or (5) colonoscopy every 10 years.
The USPSTF released its updated recommendations for colorectal cancer screening in July 2002.
The USPSTF strongly recommends that clinicians screen men and women 50 years of age or older
for colorectal cancer (A recommendation). The USPSTF found good evidence for FOBT screening,
fair evidence for sigmoidoscopy (alone or in combination with FOBT), and no direct evidence for
colonoscopy or double contrast barium enema. The USPSTF found insufficient evidence to
recommend new technologies, such as virtual colonoscopy. The recommended periodicity is
annually for FOBT, every 5 years for sigmoidoscopy and double contrast barium enema, and every
10 years for colonoscopy. FOBT is the only test for which direct evidence on periodicity exists. The
intervals for the other tests are based on their sensitivity and the natural course of the disease.

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Measure #114: Inquiry Regarding Tobacco Use
DESCRIPTION:
Percentage of patients aged 18 years or older who were queried about tobacco use one or more
times within 24 months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients seen during
the reporting period. Tobacco use is to be queried at least once within 24 months prior to the date
of service. There is no diagnosis associated with this measure. This measure may be reported by
clinicians who perform the quality actions described in the measure based on the services provided
and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. CPT Category II codes are used to report the
numerator of the measure.
When reporting the measure, submit the listed CPT E/M service codes, and the appropriate CPT
Category II codes OR the CPT Category II code with the modifier. The modifier allowed for this
measure is: 8P- reasons not otherwise specified. There are no allowable performance exclusions
for this measure.
NUMERATOR:
Patients who were queried about tobacco use one or more times within 24 months
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Tobacco Use Assessed
(Two CPT II codes [1000F & 10xxF] are required on the claim form to submit this category)
CPT II 1000F: Tobacco use assessed
AND

OR

CPT II 1034F: Current tobacco smoker
OR
CPT II 1035F: Current smokeless tobacco user
OR
CPT II 1036F: Current tobacco non-user

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Tobacco Use not Assessed, Reason not Specified
(One CPT II code [1000F-8P] is required on the claim form to submit this category)
Append a reporting modifier (8P) to CPT Category II code 1000F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 1000F with 8P: Tobacco use not assessed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215
RATIONALE:
Tobacco use is one of the leading causes of many preventable diseases, however, not all
individuals are screened for tobacco use.
CLINICAL RECOMMENDATION STATEMENTS:
Periodic screening for tobacco use is recommended for all patients. (US Department of Health and
Human Services, USPSTF)
Tobacco cessation counseling is recommended for all patients who smoke. (USPSTF)

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Measure #115: Advising Smokers to Quit
DESCRIPTION:
Percentage of patients aged 18 years and older and are smokers who received advice to quit
smoking
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients (whether or
not they use tobacco) seen during the reporting period. There is no diagnosis associated with this
measure. This measure is appropriate for use in all healthcare settings. This measure may be
reported by clinicians who perform the quality actions described in the measure based on the
services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT E/M service codes and patient demographics (age, gender, etc.) are used to identify patients
who are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who received advice to quit smoking
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Identify Tobacco Smokers Receiving Cessation Intervention
(Two G-codes [G8455 & G8402] are required on the claim form to submit this category)

OR

G8455: Current tobacco smoker
AND
G8402: Tobacco (smoke) use cessation intervention, counseling
If patient is not eligible for this measure because patient is a smokeless tobacco
user or a non tobacco user, report:
(One G-code [G84xx] is required on the claim form to submit this category)
Smokeless Tobacco User
G8456: Current smokeless tobacco user
OR
Tobacco Non-User
G8457: Tobacco non-user

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OR

Tobacco Smokers not Advised to Quit, Reason not Specified
(Two G-codes [G8455 & G8403] are required on the claim form to submit this category)
G8455: Current tobacco smoker
AND
G8403: Tobacco (smoke) use cessation intervention not counseled

DENOMINATOR:
All patients aged 18 years and older
Denominator Coding:
A CPT E/M service code is required to identify patients for denominator inclusion.
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Interventions to control smoking are strategically important because smoking is the leading
preventable cause of death in the United States, clinical interventions are known to be effective in
increasing cessation rates, and quitting smoking has been shown to improve health outcomes
(Fiore, 2000)
CLINICAL RECOMMENDATION STATEMENTS:
The Clinical Practice Guidelines: Treating tobacco use and dependence published by USDHHS
Public Health Service (Fiore, 2002) provide convincing empirical support for providing advice to
and assistance with quitting smoking for patients who smoke. Specifically, these guidelines
recommend:
1) repeated advice and support at all or most visits, and
2) delivery of cessation assistance and follow-up at all or most visits.
There have been more than 12 million premature deaths attributable to smoking since the first
published Surgeon General’s report on smoking and health in 1964. Smoking remains the leading
preventable cause of premature death in the United States.
Nearly every organ in the body is affected by smoking (USDHHS, 2004). Smoking causes many
diseases and reduces the health of smokers in general. The list of diseases caused by smoking
has been expanded to include abdominal aortic aneurysm, acute myeloid leukemia, cataract,
cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis, and stomach cancer
(USDHHS, 2004).
In the US in 2003, 45.4 million adults (21.6 percent) were current smokers—24.1 percent of men
and 19.2 percent of women (CDC, 2005a). An estimated 70% of these smokers said they wanted
to quit (CDC, 2005a).
An estimated 45.9 million adults were former smokers in 2003, representing 50.3 percent of those
who had ever smoked (CDC, 2005a). For the second consecutive year, more adults had quit than
were still smoking. A large number of clinical trials have demonstrated the effectiveness of
counseling in increasing cessation rates, and the effectiveness of bupropion and NRT has been

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demonstrated (Fiore, 2000). A meta-analysis of 7 studies found that physician advice to quit is
associated with a 30% increase in cessation rates (Fiore, 2000). Counseling and medication are
each associated with a doubling of cessation rates (Fiore, 2000).

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Measure #116: Inappropriate Antibiotic Treatment for Adults with Acute Bronchitis
DESCRIPTION:
Percentage of adults aged 18 through 64 years with a diagnosis of acute bronchitis who were not
prescribed or dispensed an antibiotic prescription on or within 3 days of the initial date of service
INSTRUCTIONS:
This measure is to be reported at each visit for acute bronchitis during the reporting period. This
measure may be reported by clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II code OR the CPT Category II code with the modifier. The
modifier allowed for this measure is: 1P- medical reasons.
NUMERATOR:
Patients who were not prescribed or dispensed antibiotics on or within 3 days of the initial date of
service
Numerator Instructions: For performance, the measure will be calculated as the number
of patients for whom antibiotics were neither prescribed nor dispensed on or within 3 days
of the initial date of service over the number of patients in the denominator (patients aged
18 through 64 years with acute bronchitis). A higher score indicates appropriate treatment
of patients with acute bronchitis (e.g., the proportion for whom antibiotics were not
prescribed or dispensed on or three days after the initial date of service).
Numerator Coding:
Table 1A: The antibiotics listed below are considered antibiotics for the purposes of this
measure.
Description
Prescription
5-aminosalicylates
sulfasalazine
Amebicides
metronidazole
Aminoglycosides
amikacin
kanamycin
gentamicin
neomycin
Aminopenicillins
amoxicillin
ampicillin
Antipseudomonal
piperacillin
ticarcillin
penicillins
Beta-lactamase
amoxicillinpiperacillininhibitors
clavulanate
tazobactam

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streptomycin
tobramycin

ticarcillinclavulanate

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First generation
cephalosporins
Fourth generation
cephalosporins
Ketolides
Lincomycin
derivatives
Macrolides

Miscellaneous
antibiotics
Sulfamethoxazoletrimethoprim DS
Natural penicillins

Penicillinase
resistant penicillins
Quinolones
Rifamycin
derivatives
Second generation
cephalosporin
Sulfonamides
Tetracyclines
Third generation
cephalosporins
Urinary antiinfectives

ampicillinsulbactam
cefadroxil
cefazolin
cefepime
telithromycin
clindamycin

cephalexin
cephradine

lincomycin

azithromycin
clarithromycin

erythromycin
erythromycin
ethylsuccinate

aztreonam
chloramphenicol
dalfopristinquinupristin
doxycycline

daptomycin
erythromycinsulfisoxazole
linezolid
sulfamethoxazo
le-trimethoprim
penicillin G
procaine
penicillin G
sodium

penicillin G
benzathineprocaine
penicillin G
potassium
dicloxacillin
ciprofloxacin
gatifloxacin
gemifloxacin
rifampin

erythromycin
lactobionate
erythromycin
stearate
metronidazole

vancomycin
penicillin V
potassium

nafcillin

oxacillin

levofloxacin
lomefloxacin
moxifloxacin

Norfloxacin
ofloxacin
sparfloxacin

cefaclor
cefoxitin
cefuroxime
cefotetan
cefprozil
loracarbef
sulfadiazine
sulfisoxazole
sulfamethoxazole-trimethoprim
doxycycline
minocycline
tetracycline
cefdinir
cefotaxime
ceftibuten
cefixime
ceftazidime
ceftriaxone
cefoperazone
fosfomycin
nitrofurantoin macrocrystals-monohydrate
nitrofurantoin
trimethoprim
nitrofurantoin
macrocrystals

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Antibiotic not Prescribed or Dispensed
CPT II 4124F: Antibiotic neither prescribed nor dispensed
OR

OR

Antibiotic Prescribed or Dispensed for Medical Reasons
Append a modifier (1P) to CPT Category II code 4120F to report documented
circumstances that appropriately exclude patients from the denominator.
• 1P: Documentation of medical reason(s) for prescribing or dispensing antibiotic
Antibiotic Prescribed or Dispensed
CPT II 4120F: Antibiotic prescribed or dispensed

DENOMINATOR:
All patients aged 18 through 64 years with a diagnosis of acute bronchitis
Denominator Coding:
An ICD-9 diagnosis code for acute bronchitis and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes: 466.0
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245, 99341,
99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Antibiotics are commonly misused and overused for a number of viral respiratory conditions where
antibiotic treatment is not clinically indicated. (Scott J.G., D. Cohen, B. Dicicco-Bloom, 2001) About
80 percent of antibiotics prescribed for acute respiratory infections in adults are unnecessary,
according to CDC prevention guidelines. In adults, antibiotics are most often (65–80 percent)
prescribed for acute bronchitis, despite its viral origin. The misuse and overuse of antibiotics
contributes to antibiotic drug resistance, which is of public health concern due to the diminished
efficacy of antibiotics against bacterial infections, particularly in sick patients and the elderly.
(Austin D.J., K.G. Kristinsson, R.M. Anderson, 1999, Patterson, JE, 2001, Cohen ML, 1992,
Lipsitch M, 2001)
A HEDIS measure that highlights inappropriate antibiotic prescribing in adults for a common
respiratory condition will help to raise awareness among clinicians and patients about inappropriate
antibiotic use. Antibiotics are most often inappropriately prescribed in adults with acute bronchitis.
This measure builds on an existing HEDIS measure targeting inappropriate antibiotic prescribing
for children with upper respiratory infection (common cold), where antibiotics are also most often
inappropriately prescribed. (Chandran R., 2001, Gonzales R., J.F. Steiner, et al., 1999)
CLINICAL RECOMMENDATION STATEMENTS:
Clinical guidelines do not support antibiotic treatment of otherwise healthy adults with acute
bronchitis due to the viral origin of acute bronchitis. Patients with chronic bronchitis, COPD or other
chronic comorbidity may be treated with antibiotics and are therefore excluded from the measure
denominator. (Gonzales R., D.C. Malone, J.H. Maselli, et al, 2001)

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Measure #117: Dilated Eye Exam in Diabetic Patient
DESCRIPTION:
Percentage of patients aged 18 through 75 years with a diagnosis of diabetes mellitus who had a
dilated eye exam
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. This measure may be reported by clinicians who perform
the quality actions described in the measure based on services provided and the measure-specific
denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT codes, and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting
modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable
performance exclusions for this measure.
NUMERATOR:
Patients who had a dilated eye exam for diabetic retinal disease at least once within 12 months
Numerator Instructions: This includes patients with diabetes who had one of the
following: A retinal or dilated eye exam by an eye care professional (optometrist or
ophthalmologist) during the reporting period, or a negative retinal exam (no evidence of
retinopathy) by an eye care professional in the year prior to the reporting period. For
dilated eye exams performed 12 months prior to the reporting period, an automated result
must be available.
Numerator Coding:
Dilated Eye Exam Performed by an Eye Care Professional
CPT II 2022F: Dilated retinal eye exam with interpretation by an ophthalmologist or
optometrist documented and reviewed
OR
CPT II 2024F: Seven standard field stereoscopic photos with interpretation by an
ophthalmologist or optometrist documented and reviewed
OR
CPT II 2026F: Eye imaging validated to match diagnosis from seven standard field
stereoscopic photos results documented and reviewed
OR
CPT II 3072F: Low risk for retinopathy (no evidence of retinopathy in the prior year)
OR

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Dilated Eye Exam not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 2022F or 2024F or 2026F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
• 8P: Dilated eye exam was not performed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 through 75 years with a diagnosis of diabetes
Denominator Coding:
An ICD-9 diagnosis code for diabetes and a CPT code are required to identify patients for
denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2,
362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 366.41, 648.00, 648.01, 648.02,
648.03, 648.04
AND
CPT codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99212,
99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244, 99245,
99455, 99456
RATIONALE:
Examination of the eyes is the first step in the treatment of any existing or developing conditions
related to retinopathy and the first step in the prevention of blindness.
CLINICAL RECOMMENCATION STATEMENTS:
AACE/ACE, ADA, and American Academy of Ophthalmology (AAO): Recommend that a dilated
eye examination be performed on patients with diabetes during an initial assessment and at least
annually thereafter. (AACE/ACE, 2002; ADA, 2004; AAO, 1998; Hammond, 1998)
American Association of Clinical Endocrinologists and American College of Endocrinology
(AACE/ACE): Recommend that the annual eye examination be performed as part of a retinal
module. The module includes test of visual acuity (Snellen chart); funduscopic examination and
intraocular pressure (IOP) test. The AACE/ACE recommends that diabetic patients should be
under the care of an ophthalmologist experienced in the management of diabetic retinopathy.
AACE/ACE further believes that a dilated eye exam should only be done by an MD/DO.
(AACE/ACE, 2002)
American Diabetes Association (ADA): Patients with type 1 diabetes should have an initial dilated
and comprehensive eye examination by an ophthalmologist or optometrist within 3-5 years after
the onset of diabetes. In general evaluation for diabetic eye disease is not necessary before 10
years of age. However, some evidence suggests that the prepubertal duration of diabetes may be
important in the development of microvascular complications; therefore, clinical judgment should
be used when applying these recommendations to individual patients. (Level of Evidence: B)

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Patients with type 2 diabetes should have an initial dilated and comprehensive eye examination by
an ophthalmologist or optometrist shortly after diabetes diagnosis. (Level of Evidence: B)
Subsequent examinations for type 1 and type 2 diabetic patients should be repeated annually by
an ophthalmologist or optometrist who is knowledgeable and experienced in diagnosing the
presence of diabetic retinopathy and is aware of its management. Examination will be required
more frequently if retinopathy is progressing. This follow-up interval is recommended recognizing
that there are limited data addressing this issue. (Level of Evidence: B)
Seven standard field stereoscopic 30° fundus photography is an accepted method for examining
diabetic retinopathy. (ADA, 2004)
American Academy of Ophthalmology (AAO): Recommends that diabetic patients should be under
the care of an ophthalmologist experienced in the management of diabetic retinopathy.
Ophthalmologists with specialized knowledge and experience in managing the disease are best
able to detect and treat serious disease. Stereoscopic photographs offer an advantage over
nonstereoscopic photographs, and the traditional “seven stereo fields” provide the most complete
coverage. (AAO, 1998; Hammond, 1996)
American Geriatrics Society (AGS): Dilated eye examinations should be performed every two years
at a minimum, and more often if there are additional risk factors for diabetic eye disease or
evidence of age-related eye disease. (CHF/AGS, 2003)

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Measure #118: Angiotensin Converting Enzyme Inhibitor (ACE) or Angiotensin Receptor
Blocker (ARB) Therapy for Patients with Coronary Artery Disease and Diabetes and/or Left
Ventricular Systolic Dysfunction (LVSD)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD)
who also have diabetes mellitus and/or left ventricular systolic dysfunction (LVSD) who were
prescribed ACE Inhibitor or ARB therapy
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with CAD
seen during the reporting period. This measure may be reported by clinicians who perform the
quality actions described in the measure based on the services provided and the measure-specific
denominator coding.
There are two reporting options for this measure:
(1) Patients who are 18 years and older with a diagnosis of CAD who also have LVSD who
are prescribed ACE Inhibitor or ARB therapy
OR
(2) Patients who are 18 years and older with a diagnosis of CAD who are also diabetic who
are prescribed ACE Inhibitor or ARB therapy.
This measure is reported using G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. G-codes are used to
report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
REPORTING OPTION 1: For patients with CAD and LVSD
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
Numerator Instructions: The LVSD may be determined by quantitative or qualitative
assessment. Examples of a quantitative or qualitative assessment may include an
echocardiogram: 1) that provides a numerical value of LVSD or 2) that uses descriptive
terms such as moderately or severely depressed left ventricular dysfunction.
Numerator Coding:
ACE Inhibitor or ARB Therapy Prescribed
G8468: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy prescribed for patients with a left ventricular ejection fraction (LVEF) <40%
or documentation of moderately or severely depressed left ventricular systolic function
OR

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ACE Inhibitor or ARB Therapy not Prescribed for Documented Reasons
G8469: Clinician documented that patient with a left ventricular ejection fraction (LVEF)
<40% or documentation of moderately or severely depressed left ventricular systolic
function was not an eligible candidate for angiotensin converting enzyme (ACE) inhibitor or
angiotensin receptor blocker (ARB) therapy
OR
If patient is not eligible for this measure because LVEF ≥ 40% or LVEF not
performed or documented, report:
Left Ventricular Ejection Fraction (LVEF) ≥ 40%
G8470: Patient with left ventricular ejection fraction (LVEF) ≥40% or documentation as
normal or mildly depressed left ventricular systolic function
OR
Left Ventricular Ejection Fraction (LVEF) not Performed or Documented
G8471: Left ventricular ejection fraction (LVEF) was not performed or documented
OR

ACE Inhibitor or ARB Therapy not Prescribed for Patients with LVSD, Reason not
Specified
G8472: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy not prescribed for patients with a left ventricular ejection fraction (LVEF)
<40% or documentation of moderately or severely depressed left ventricular systolic
function, reason not specified

DENOMINATOR:
All CAD patients aged 18 years and older who also have a diagnosis of LVSD
Denominator Coding:
An ICD-9 diagnosis code for CAD and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes for CAD: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52,
410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91,
410.92, 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02,
414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350

OR

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REPORTING OPTION 2: For patients with CAD and diabetes
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy
Numerator Coding:
ACE Inhibitor or ARB Therapy Prescribed
G8473: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy prescribed
OR

OR

ACE Inhibitor or ARB Therapy not Prescribed for Documented Reasons
G8474: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy not prescribed for reasons documented by the clinician
ACE Inhibitor or ARB Therapy not Prescribed, Reason not Specified
G8475: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy not prescribed, reason not specified

DENOMINATOR:
All CAD patients aged 18 years and older who also have a diagnosis of diabetes
Denominator Coding:
ICD-9 diagnosis codes for CAD and diabetes and a CPT E/M service code are required to
identify patients for denominator inclusion.
ICD-9 diagnosis codes for CAD: 410.00, 410.01, 410.02, 410.10, 410.11, 410.12, 410.20,
410.21, 410.22, 410.30, 410.31, 410.32, 410.40, 410.41, 410.42, 410.50, 410.51, 410.52,
410.60, 410.61, 410.62, 410.70, 410.71, 410.72, 410.80, 410.81, 410.82, 410.90, 410.91,
410.92, 411.0, 411.1, 411.81, 411.89, 413.0, 413.1, 413.9, 414.00, 414.01, 414.02,
414.03, 414.04, 414.05, 414.06, 414.07, 414.8, 414.9, V45.81, V45.82
AND
ICD-9 diagnosis codes for diabetes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11,
250.12, 250.13, 250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40,
250.41, 250.42, 250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63,
250.70, 250.71, 250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92,
250.93, 648.00, 648.01, 648.02, 648.03, 648.04
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309,
99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342,
99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
In the absence of contraindications, ACE inhibitors or ARBs are recommended for patients with
coronary artery disease; especially those with diabetes and /or left ventricular systolic dysfunction.
ACE inhibitors and ARBs have shown to decrease morbidity and mortality, including significant
reductions in the occurrence of myocardial infarction, stroke, and diabetic complications.

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CLINICAL RECOMMENDATION STATEMENTS:
ACE inhibitor use is recommended in all patients with CAD who also have diabetes and/or left
ventricular systolic dysfunction. (ACC/AHA)
ACE inhibitor use is also recommended in patients with CAD or other vascular disease.
(ACC/AHA)
In ST elevation myocardial infarction (STEMI) patients who tolerate ACE inhibitors, an angiotensin
receptor blocker (ARB) can be useful as an alternative to ACE inhibitors in the long-term
management of STEMI patients, provided there are either clinical or radiological signs of heart
failure or LVEF less than 0.40. (ACC/AHA)

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Measure #119: Urine Screening for Microalbumin or Medical Attention for Nephropathy in
Diabetic Patients
DESCRIPTION:
Percentage of patients aged 18 through 75 years of age with diabetes mellitus who received urine
protein screening or medical attention for nephropathy during at least one office visit within 12
months
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for all patients with
diabetes mellitus seen during the reporting period. This measure may be reported by clinicians who
perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
This measure is reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. CPT Category II codes are used
to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT codes, and the
appropriate CPT Category II code OR the CPT Category II code with the modifier. The reporting
modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable
performance exclusions for this measure.
NUMERATOR:
Patients who have a nephropathy screening during at least one office visit within 12 months
Numerator Instructions: This measure is looking for a nephropathy screening test or
evidence of nephropathy.

OR

Numerator Coding:
Nephropathy Screening Performed
CPT II 3060F: Positive microalbuminuria test result documented and reviewed
OR
CPT II 3061F: Negative microalbuminuria test result documented and reviewed
OR
CPT II 3062F: Positive macroalbuminuria test result documented and reviewed
OR
CPT II 3066F: Documentation of treatment for nephropathy (eg, patient receiving dialysis,
patient being treated for ESRD, CRF, ARF, or renal insufficiency, any visit to a
nephrologist)
OR
CPT II 4009F: Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor
blocker (ARB) therapy prescribed

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Nephropathy Screening not Performed, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3060F or 3061F or 3062F to
report circumstances when the action described in the numerator is not performed and the
reason is not otherwise specified.
• 8P: Nephropathy screening was not performed, reason not otherwise specified
DENOMINATOR:
All patients aged 18 through 75 years of age with the diagnosis of diabetes
Denominator Coding:
An ICD-9 diagnosis code for diabetes and a CPT code are required to identify patients for
denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93, 357.2,
362.01, 362.02, 362.03, 362.04, 362.05, 362.06, 362.07, 648.00, 648.01, 648.02, 648.03,
648.04
AND
CPT codes: 92002, 92004, 92012, 92014, 99201, 99202, 99203, 99204, 99205, 99211,
99212, 99213, 99214, 99215, 99217, 99218, 99219, 99220, 99241, 99242, 99243, 99244,
99245, 99455, 99456
RATIONALE:
Nephropathy is a frequent complication of renal disease for both type 1 and type 2 diabetes and
often ends in end-stage renal disease (ESRD) (ADA, 2002). Of all people with diabetes, 10-21%
have nephropathy (ADA 2002).
CLINICAL RECOMENNDATION STATEMENTS:
American Association of Clinical Endocrinologists and American College of Endocrinology
(AACE/ACE): Recommends that the initial assessment should include a urinalysis, test for
microalbuminuria and creatinine clearance. The renal complication module should be performed
annually and includes a test for microalbuminuria and creatinine clearance (AACE/ACE, 2002).
American Diabetes Association (ADA): A test for the presence of microalbumin should be
performed at diagnosis in patients with type 2 diabetes. Microalbuminuria rarely occurs with short
duration of type 1 diabetes; therefore, screening in individuals with type 1 diabetes should begin
after 5 years' disease duration (Level of Evidence: E). However, some evidence suggests that the
prepubertal duration of diabetes may be important in the development of microvascular
complications; therefore, clinical judgment should be exercised when individualizing these
recommendations. Because of the difficulty in precise dating of the onset of type 2 diabetes, such
screening should begin at the time of diagnosis. After the initial screening and in the absence of
previously demonstrated microalbuminuria, a test for the presence of microalbumin should be
performed annually (ADA, 2004).
Screening for microalbuminuria can be performed by three methods:

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1)measurement of the albumin-to-creatinine ratio in a random spot collection
2)24-h collection with creatinine, allowing the simultaneous measurement of creatinine clearance
3)timed (e. g. 4-h or overnight) collection – the analysis of a spot sample for the albumin-tocreatinine ratio is strongly recommended.
The role of annual microalbuminuria assessment is less clear after diagnosis of microalbuminuria
and institution of angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker
(ARB) therapy and blood pressure control. Many experts recommend continued surveillance to
assess both response to therapy and progression of disease.
National Kidney Foundation (NKF): Individuals at increased risk, but found not to have chronic
kidney disease, should be advised to follow a program of risk factor reduction, if appropriate, and
undergo repeat periodic evaluation (NKF, 2003).
A comparative analysis of recommendations and evidence in diabetes guidelines from 13 countries
(including the American Diabetes Association and Canadian Medical Association) found there was
agreement among the guidelines that ACE inhibitors should be recommended to patients with
hypertension and renal disease (Burgers, 2002).
The ADA also recommends that for the treatment of both micro- and macroalbuminurua, ARBs
should be used except during pregnancy (ADA, 2005).

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Measure #120: ACE Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy in Patients
with CKD
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced chronic kidney
disease (CKD) (stage 4 or 5, not receiving Renal Replacement Therapy [RRT]), and hypertension
and proteinuria who were prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy during the 12-month reporting period
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with CKD seen
during the reporting period. It is anticipated that clinicians providing care for patients with CKD will
submit this measure.
This measure may be reported using G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. G-codes are used to
report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who were prescribed ACE inhibitor or ARB therapy during the 12 month reporting period
Numerator Coding:
ACE Inhibitor or ARB Therapy Prescribed
G8479: Clinician prescribed angiotensin converting enzyme (ACE) inhibitor or angiotensin
receptor blocker (ARB) therapy
OR

OR

ACE Inhibitor or ARB Therapy not Prescribed for Documented Reasons
G8480: Clinician documented that patient was not an eligible candidate for angiotensin
converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) therapy
ACE Inhibitor or ARB Therapy not Prescribed, Reason not Specified
G8481: Clinician did not prescribe angiotensin converting enzyme (ACE) inhibitor or
angiotensin receptor blocker (ARB) therapy, reason not specified

DENOMINATOR:
All patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not
receiving RRT) and hypertension and proteinuria

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Denominator Coding:
An ICD-9 diagnosis code for CKD, hypertension, and proteinuria, and a CPT E/M service
code are required to identify patients for denominator inclusion.
ICD-9 diagnosis codes for CKD: 585.4, 585.5
AND
ICD-9 diagnosis codes for hypertension: 401.0, 401.1, 401.9, 402.00, 402.01, 402.10,
402.11, 402.90, 402.91, 403.00, 403.01, 403.10, 403.11, 403.90, 403.91, 404.00, 404.01,
404.02, 404.03, 404.10, 404.11, 404.12, 404.13, 404.90, 404.91, 404.92, 404.93
AND
ICD-9 diagnosis codes for proteinuria: 791.0
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Evidence has shown that use of ACE inhibitors and ARBs as antihypertensive therapy is effective,
and may help slow the progression of CKD. These drugs help control hypertension and decrease
proteinuria. However, data shows that only approximately one-third of patients with CKD are
treated with an ACE inhibitor or an ARB.
Process/goal of care to be improved: Percentage of pts on ACEI or ARB and thereby slowing
progression of CKD.
CLINICAL RECOMMENDATION STATEMENTS:
If a patient has GFR ≤ 30 ml/min/1.73m² and hypertension, then s/he should receive an ACE
inhibitor or an ARB as a first-line agent (Grade C). (RPA 2002)
ACE inhibitors and ARBs can be used safely in most patients with CKD. ACE Inhibitors and ARBs
should be used at moderate to high doses, as used in clinical trials (Grade A). (NKF 2004)
ACE inhibitors and ARBs have not been tested in all types of CKD. Where tested, ACE inhibitors
and ARBs have generally similar effects on blood pressure, urine protein excretion, and slowing
the progression of kidney disease (Strength of Recommendation: STRONG). (NKF 2004)

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Measure #121: Chronic Kidney Disease (CKD): Laboratory Testing (Calcium, Phosphorus,
Intact Parathyroid Hormone (iPTH) and Lipid Profile)
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of advanced CKD (stage 4 or 5,
not receiving Renal Replacement Therapy [RRT]), who had the following laboratory testing ordered
at least once during the 12-month reporting period: serum levels of calcium, phosphorus and intact
PTH, and lipid profile
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients with CKD seen
during the reporting period. It is anticipated that clinicians providing care for patients with CKD will
submit this measure.
This measure may be reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifiers allowed for this measure are: 1P- medical reasons, 2P- patient reasons, 8P- reasons not
otherwise specified.
NUMERATOR:
Patients who had the following laboratory testing ordered at least once during the 12 month
reporting period: serum levels of calcium, phosphorus and intact PTH, and lipid profile
Numerator Coding:
Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile Ordered
CPT II 3278F: Serum levels of calcium, phosphorus, intact Parathyroid Hormone (iPTH)
and lipid profile ordered
OR

Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile not Ordered for Medical or Patient Reasons
Append a modifier (1P or 2P) to CPT Category II code 3278F to report documented
circumstances that appropriately exclude patients from the denominator
• 1P: Documentation of medical reason(s) for not ordering serum levels of calcium,
phosphorus, intact Parathyroid Hormone (iPTH) and lipid profile
• 2P: Documentation of patient reason(s) for not ordering serum levels of calcium,
phosphorus, intact Parathyroid Hormone (iPTH) and lipid profile

OR

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Serum Levels of Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid
Profile not Ordered, Reason not Specified
Append a reporting modifier (8P) to CPT Category II code 3278F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 8P: Serum levels of calcium, phosphorus, intact Parathyroid Hormone (iPTH) and lipid
profile not ordered, reason not otherwise specified
DENOMINATOR:
All patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5, not
receiving RRT)
Denominator Coding:
An ICD-9 diagnosis code for CKD and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 585.4, 585.5
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
Bone disease is a common complication of chronic kidney disease. Patients with CKD should be
monitored for calcium and phosphate imbalances and secondary hyperparathyroidism.
Disturbances in mineral and bone metabolism are prevalent in CKD and are an important cause of
morbidity, decrease in quality of life, and extraskeletal calcification that has been associated with
increased CV mortality (taken verbatim from Definition, evaluation, and classification of renal
osteodystrophy: a position statement from the Kidney Disease: Improving Global Outcomes
(KDIGO), Moe, et al, Kidney Int, 2006; 69:1945-53). Gaps: USRDS 2006 data show that less than
30% of Medicare (and less than 20% of EGHP) pts receive Ca, Phos, PTH measures within a year.
Process/goal of care to be improved: identification of abnormalities mineral and bone metabolism
that relate to increased morbidity and mortality.
CLINICAL RECOMMENDATION STATEMENTS:
Serum levels of calcium, phosphorus, and intact plasma parathyroid hormone (PTH) should be
measured in all patients with CKD and GFR < 60 ml/min/1.73m². (Evidence) (NKF 2003)
If a patient has GFR ≤ 30 ml/min/1.73m², then s/he should have his/her serum calcium and
phosphorus measured at least every three months, and iPTH levels measured at least once.
(Grade B) (RPA 2002)
Patients with CKD should be considered in the “highest-risk” group for CVD for implementing
recommendations for pharmacological therapy, irrespective of cause of CKD. (Grade A) (NKF
2004)
All adults and adolescents with CKD should be evaluated for dyslipidemias. (Grade B) (NKF 2003)

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For adults and adolescents with CKD, the assessment of dyslipidemias should include a complete
fasting lipid profile with total cholesterol, LDL, HDL, and triglycerides. (Grade B) (NKF 2003)

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Measure #122: Chronic Kidney Disease (CKD): Blood Pressure Management
DESCRIPTION:
Percentage of patient visits for patients aged 18 years and older with a diagnosis of advanced CKD
(stage 4 or 5, not receiving Renal Replacement Therapy [RRT]), with a blood pressure < 130/80
mmHg OR blood pressure ≥ 130/80 mmHg with a documented plan of care
INSTRUCTIONS:
This measure is to be reported at each visit for patients with a diagnosis of CKD seen during the
reporting period. It is anticipated that clinicians providing care for patients with CKD will submit this
measure.
This measure is reported using G-codes and/or CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. G-codes and/or CPT
Category II codes are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes and
the appropriate G-code AND/OR CPT Category II code OR the CPT Category II code with the
modifier AND G-code. The reporting modifier allowed for this measure is: 8P- reasons not
otherwise specified. There are no allowable performance exclusions for this measure.
NUMERATOR:
Patients visits with blood pressure <130/80 mmHg OR ≥130/80 mmHg with a documented plan of
care
Definition: A documented plan of care should include one or more of the following:
recheck blood pressure at specified future date; initiate or alter pharmacologic therapy;
initiate or alter non-pharmacologic therapy; documented review of patient’s home blood
pressure log which indicates that patient’s blood pressure is or is not well controlled.
Numerator Instructions: If multiple blood pressure measurements are taken at a single
visit, use the most recent measurement taken at that visit.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Patient Visits with Blood Pressure < 130/80 mmHg
(One G-code [G8476] is required on the claim form to submit this category)
G8476: Most recent blood pressure has a systolic measurement of <130 mmHg and
a diastolic measurement of <80 mmHg

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OR
Blood Pressure Plan of Care Documented for Patient Visits with Systolic Blood
Pressure ≥ 130 mmHG and/or Diastolic Blood Pressure ≥ 80 mmHg (If either systolic
blood pressure is ≥ 130 mmHg OR diastolic blood pressure is ≥ 80 mmHg, patient
requires a plan of care)
(One G-code & one CPT II code [G8477 & 0513F] are required on the claim form to submit
this category)
G8477: Most recent blood pressure has a systolic measurement of ≥130 mmHg and/or a
diastolic measurement of ≥80 mmHg
AND
CPT II 0513F: Elevated blood pressure plan of care documented
OR

Blood Pressure Measurement not Performed
(One G-code [G8478] is required on the claim form to submit this category)
G8478: Blood pressure measurement not performed or documented, reason not specified
OR
Elevated Blood Pressure Plan of Care not Documented for Patient Visits with
Systolic Blood Pressure ≥ 130 mmHg and/or Diastolic Blood Pressure ≥ 80 mmHg,
Reason not Specified
(One CPT II code & one G-code [0513F-8P & G8477] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 0513F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 0513F with 8P: No documentation of elevated blood pressure plan of care, reason not
otherwise specified
AND
G8477: Most recent blood pressure has a systolic measurement of ≥130 mmHg
and/or a diastolic measurement of ≥80 mmHg

DENOMINATOR:
All visits for patients aged 18 years and older with the diagnosis of advanced CKD (stage 4 or 5,
not receiving RRT)
Denominator Coding:
An ICD-9 diagnosis code for CKD and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 585.4, 585.5
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245

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RATIONALE:
Identification of hypertension in patients with CKD is an essential part of management of the
disease. Hypertension is common in patients with CKD, and if hypertension is left untreated, it will
speed the progression of the disease. Recent research has shown that during office visits,
approximately 20% to 30% of CKD patients do not have their blood pressure measured.
Additionally, if the CKD patient is has an anemia/ESA visit, they are even less likely to have their
blood pressure measured. In these patients, recent research has shown that 75% do not have their
blood pressure measured at an anemia/ESA visit. Patients with CKD should have their blood
pressure measured at each office visit so that changes can be identified and treatment initiated as
soon as it is necessary. Blood pressure control is important in slowing the progression of chronic
kidney disease. By slowing the progression of the disease, quality of life is improved for the patient,
and it results in a longer period of time before a patient requires renal replacement therapy.
Patients with chronic kidney disease should have a lower target blood pressure (< 130/80) than
other patients with hypertension.
CLINICAL RECOMMENDATION STATEMENTS:
Blood pressure should be measured at each health encounter. (Grade A) (NKF 2004)
If a patient has GFR ≤ 30 ml/min/1.73m2, then his/her blood pressure should be checked with
every clinic visit. (Grade A) (RPA 2002)
If a patient has a GFR ≤ 30 ml/min/1.73m², and if blood pressure is determined to be elevated
(systolic > 130 mmHg OR diastolic > 80 mmHg), then s/he should receive intensified
antihypertensive therapy (Grade B). (RPA, 2002)
Patients with CKD should be considered in the “highest-risk” group for CVD for implementing
recommendations for pharmacological therapy, irrespective of cause of CKD (Grade A). (NKF,
2004)
Target blood pressure for CVD risk reduction in CKD and diabetic/nondiabetic kidney disease
should be < 130/80 mmHg (Grade B). (NKF, 2004)

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Measure #123: Chronic Kidney Disease (CKD): Plan of Care: Elevated Hemoglobin for
Patients Receiving Erythropoiesis-Stimulating Agents (ESA)
DESCRIPTION:
Percentage of patient calendar months during the 12-month reporting period in which patients aged
18 years and older with a diagnosis of advanced CKD (stage 4 or 5, not receiving Renal
Replacement Therapy [RRT]), receiving ESA therapy, have a hemoglobin < 13 g/dL OR patients
whose hemoglobin is ≥ 13 g/dL and have a documented plan of care
INSTRUCTIONS:
This measure is to be reported each calendar month patients are seen with a diagnosis of
advanced CKD (stage 4 or 5) during the reporting period. The most recent quality code submitted
will be used for performance calculation. It is anticipated that clinicians providing care for patients
with CKD will submit this measure.
This measure may be reported using CPT Category II codes:
ICD-9 diagnosis codes, CPT E/M service codes, and patient demographics (age, gender, etc.) are
used to identify patients who are included in the measure’s denominator. CPT Category II codes
are used to report the numerator of the measure.
When reporting the measure, submit the listed ICD-9 diagnosis codes, CPT E/M service codes,
and the appropriate CPT Category II codes OR the CPT Category II code(s) with the modifier. The
modifier allowed for this measure is: 8P- reasons not otherwise specified. There are no allowable
performance exclusions for this measure.
NUMERATOR:
Number of patient calendar months during which patients with a hemoglobin level of < 13 g/dL OR
patients whose hemoglobin level is ≥ 13 g/dL have a documented plan of care
Definition: A documented plan of care should include reducing the ESA dose and
repeating hemoglobin at a specified future date.
NUMERATOR NOTE: The correct combination of numerator code(s) must be reported on
the claim form in order to properly report this measure. The “correct combination” of codes
may require the submission of multiple numerator codes.
Numerator Coding:
Hemoglobin level < 13 g/dL
(Two CPT II codes [328xF & 4171F] are required on the claim form to submit this category)
CPT II 3281F: Hemoglobin level less than 11 g/dL
OR
CPT II 3280F: Hemoglobin level 11 g/dL to 12.9 g/dL
AND

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CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agent (ESA) therapy
OR
Hemoglobin level ≥ 13 g/dL with a Documented Plan of Care
(Three CPT II codes [3279F & 0514F & 4171F] are required on the claim form to submit
this category)
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
AND
CPT II 0514F: Plan of care for elevated hemoglobin level documented for patient receiving
Erythropoiesis-Stimulating Agent (ESA) therapy
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agent (ESA) therapy
OR

If patient is not eligible for this measure because, patient was not receiving
erythropoiesis-stimulating agent (ESA) therapy, report:
(One CPT II code [4172F] is required on the claim form to submit this category)
CPT II 4172F: Patient not receiving Erythropoiesis-Stimulating Agent (ESA) therapy

OR

Hemoglobin Level Measurement not Performed
(Two CPT II codes [3281F-8P & 4171F] are required on the claim form to submit this
category)
Append a reporting modifier (8P) to CPT Category II code 3281F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 3281F with 8P: Hemoglobin level measurement not documented, reason not
otherwise specified
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agent (ESA) therapy
OR
Plan of Care for Elevated Hemoglobin Level not Documented for Patient Receiving
Erythropoiesis-Stimulating Agent (ESA) Therapy, Reason not Specified
(Three CPT II codes [0514F-8P & 3279F & 4171F] are required on the claim form to
submit this category)
Append a reporting modifier (8P) to CPT Category II code 0514F to report circumstances
when the action described in the numerator is not performed and the reason is not
otherwise specified.
• 0514F with 8P: Plan of care for elevated hemoglobin level not documented for patient
receiving Erythropoiesis-Stimulating Agent (ESA) therapy, reason not otherwise
specified

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AND
CPT II 3279F: Hemoglobin level greater than or equal to 13 g/dL
AND
CPT II 4171F: Patient receiving Erythropoiesis-Stimulating Agent (ESA) therapy
DENOMINATOR:
Calendar months for all patients aged 18 years and older with the diagnosis of advanced CKD
(stage 4 or 5, not receiving RRT), receiving ESA therapy
Denominator Coding:
An ICD-9 diagnosis code for CKD and a CPT E/M service code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 585.4, 585.5
AND
CPT E/M service codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214,
99215, 99241, 99242, 99243, 99244, 99245
RATIONALE:
The clinical recommendation regarding Hb levels for CKD patients receiving ESA therapy is that
Hb level should generally be in the range of 11.0 to 12.0 g/dL. Additionally, these patients should
also have their Hb level checked at least monthly. Given that Hb levels vary for each patient due to
numerous factors, it is necessary to monitor Hb level closely in order to make the individualized
treatment decisions required in maintaining Hb level in the target range. There is no evidence of
benefit from ESA therapy when Hb levels are maintained at greater than 13.0 g/dL. Maintaining Hb
at higher levels may result in potential harm to the patient, as well as incur unjustified cost.
Evidence linking increased risks for patients with CKD and higher Hb levels were for target Hb
levels greater than 13.0g/dL (CHOIR/CREATE). The intention of this measure is not to suggest that
the goal of ESA treatment is to reach an achieved Hb of 13.0 g/dL. Rather, as a patient safety
measures, it is to realize that patients who reach Hb levels higher than 13.0 g/dL are at increased
risk for adverse events, and that these elevated Hb levels need to be addressed by adjusting ESA
dosage.
CLINICAL RECOMMENDATION STATEMENTS:
The frequency of HB monitoring in patients treated with ESAs should be at least monthly. (Opinion)
(NKF 2006)
The Hb target is the intended aim of ESA therapy for the individual patient with CKD. In clinical
practice, achieved Hb results vary considerably from Hb target.
• Selection of the Hb target and selection of the Hb level at which ESA therapy is initiated
in the individual patient should include consideration of potential benefits (including
improvement in the quality of life and avoidance of transfusion) and potential harms
(including the risk of life-threatening adverse events). (Clinical Practice
Recommendation) (NKF 2007)
• In dialysis and nondialysis patients with CKD receiving ESA therapy, the selected Hb
target should generally be in the range of 11.0 to 12.0 g/dL. (Clinical Practice
Recommendation) (NKF 2007)

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•

In dialysis and nondialysis patients with CKD receiving ESA therapy, the Hb target
should not be greater than 13.0 g/dL. (Clinical Practice Guideline; Moderately Strong
Evidence) (NKF, 2007)

The initial ESA dose and the ESA dose adjustments should be determined by the patient’s Hb
level, the target Hb level, the observed rate of increase in Hb level, and clinical circumstances.
(Opinion) (NKF 2006)
ESA doses should be decreased, but not necessarily held, when a downward adjustment of Hb
level is needed. (Opinion) (NKF 2006)

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Measure #124: HIT - Adoption/Use of Health Information Technology (Electronic Health
Records)
DESCRIPTION:
Documents whether provider has adopted and is using health information technology. To qualify,
the provider must have adopted a qualified electronic medical record (EMR). For the purpose of
this measure, a qualified EMR can either be a Certification Commission for Healthcare Information
Technology (CCHIT) certified EMR or, if not CCHIT certified, the system must be capable of all of
the following:
• Generating a medication list
• Generating a problem list
• Entering laboratory tests as discrete searchable data elements
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients seen
during the reporting period. There is no diagnosis associated with this measure. This measure may
be reported by clinicians who have adopted and are using health information technology.
This measure is reported using G-codes:
CPT E/M codes, CPT service codes, CPT procedure codes, HCPCS D-codes and HCPCS Gcodes are used to identify patients who are included in the measure’s denominator. G-codes are
used to report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patient encounter documentation substantiates use of certified/qualified EMR
Definitions:
Health Information Technology (HIT) – A system that incorporates both computer
hardware and software that deals with the storage, retrieval, sharing, and use of health
care information, data, and knowledge for communication and decision making.
CCHIT – The Certification Commission for Healthcare Information Technology – an
independent, nonprofit organization that has been recognized by the federal government
as an official certification body for electronic health record products.
Discrete searchable data elements – Laboratory data that can be recorded in predefined
fields in predefined formats within the EMR that allow for reports to be generated, such as
trends of a specific element over time. This cannot be easily done if data is entered via a
free text format or by merely scanning a report into the EMR.
Numerator Coding:
Encounter Documented Using CCHIT Certified or Qualified EMR
G8447: Patient encounter was documented using a CCHIT certified EMR
OR

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OR

G8448: Patient encounter was documented using a non-CCHIT certified EMR. To qualify,
the system must be capable of all of the following:
• Generating a medication list
• Generating a problem list
• Entering laboratory tests as discrete searchable data elements
Encounter not Documented Using CCHIT Certified or Qualified EMR for System
Reasons
G8449: Patient encounter was not documented using an EMR due to system reasons
such as, the system being inoperable at the time of the visit. Use of this code implies that
an EMR is in place and generally available

DENOMINATOR:
All patients aged 18 years and older
Denominator Coding:
A CPT service code, CPT E/M code, HCPCS D-code or HCPCS G-code is required to
identify patients for denominator inclusion.
CPT service codes, CPT E/M codes, HCPCS D-codes or HCPCS G-codes: 90801,
90802, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150,
96151, 96152, 97001, 97002, 97003, 97004, 97750, 97802, 97803, 97804, 98940, 98941,
98942, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, D7140, D7210, G0101, G0108, G0109, G0270, G0271
RATIONALE:
The need for clinical information systems to provide high-quality, safe care is a well recognized
fact, as publicized by Dr. Ed Wagner in his Chronic Care Model. A comprehensive clinical
information system can enhance the care of individual patients by:
• Providing timely reminders about needed services
• Summarizing data to track and plan care
• Identifying groups of patients needing additional care
• Facilitating performance monitoring and quality improvement efforts
While it is preferable to encourage adoption of CCHIT certified EMRs, it became apparent during
measure field testing that CCHIT certified EMRs are not currently available for all provider settings
and specialty groups that may report this measure. Therefore, additional numerator coding was
added to enable providers who have adopted a non-CCHIT certified product, which meets a set of
standards, to also report this measure. The following is an excerpt taken from the CCHIT website:
The 2006 Ambulatory EHR Criteria represent basic requirements that the Commission and its
Workgroups believe are appropriate for many common ambulatory care settings. CCHIT
acknowledges that these Criteria may not be suitable for settings such as behavioral health,
emergency departments, or specialty practices and our current certification makes no
representation for these. Purchasers should not interpret a lack of CCHIT Certification as being of
significance for specialties and domains not yet addressed by CCHIT Criteria.

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Evidence Supporting the Criterion of the Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: better patient care management, higher patient satisfaction, reduction of adverse
drug events, better quality performance, and improved patient safety, but not consistently high
quality evidence
Committee on Quality Health Care in America (2001). Crossing the Quality Chasm: A new health
system for the 21st century. Washington, D.C., National Academy Press.
This report explains the difficulty managing a patient’s care using a written medical record,
which can be cumbersome to navigate through, as well as illegible. Not only would an
EMR be consistent and legible, it can provide reminders and prompts, allowing better
management of patient care. In addition, patients who can access their provider using email can have their needs met more quickly and cost effectively.
Study quality level 2 (limited-quality patient-oriented evidence)
Hillestad, R., et al. (2005). "Can electronic medical record systems transform health care?
Potential health benefits, savings and costs." Health Affairs 24(5): 1103-1117.
This article concludes that two-thirds of the approximately 8 million adverse drug events
that occur in the outpatient setting would be avoided through the widespread use of
computerized physician order entry (CPOE).
Study quality level 2 (limited-quality patient-oriented evidence)
Jha, A. K., et al. (2003). "Effect of the transformation of the Veterans Affairs Health Care System
on quality of care." NEJM 348(22): 2218-2227.
The Veterans Health Administration medical system uses an EMR system-wide. The
authors attribute the VHA’s superior quality performance in part to “an emphasis on the
use of information technology.”
Study quality level 2 (limited-quality patient-oriented evidence)
Middleton, B. (2005). The value of health information technology in clinical practice. Pennsylvania
eHealth Initiative, Harrisburg.
This article highlights the impact that various components of HIT and EMR will have on
improving patient safety. Additionally, Dr. Middleton enumerates the cost benefits of
ambulatory computerized physician order entry (ACPOE).
Study quality level 2 (limited-quality patient-oriented evidence)
Mitchell, E., Sullivan, F. (2001). "A descriptive feast but an evaluative famine: systematic review of
published articles on primary care computing during 1980-1997." BMJ 322(7281): 279-282.
This older systematic review documents the value of using ECI in a variety of primary care
situations.
Study quality level 2 (limited-quality patient-oriented evidence; systematic review but older)

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Measure #125: HIT - Adoption/Use of e-Prescribing
DESCRIPTION:
Documents whether provider has adopted a qualified e-Prescribing system and the extent of use in
the ambulatory setting. To qualify this system must be capable of ALL of the following:
• Generating a complete active medication list incorporating electronic data received
from applicable pharmacy drug plan(s) if available
• Selecting medications, printing prescriptions, electronically transmitting prescriptions,
and conducting all safety checks (defined below)
• Providing information related to the availability of lower cost, therapeutically
appropriate alternatives (if any)
• Providing information on formulary or tiered formulary medications, patient eligibility,
and authorization requirements received electronically from the patient’s drug plan
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients seen
during the reporting period. There is no diagnosis associated with this measure. This measure may
be reported by clinicians who have adopted a qualified e-Prescribing system.
This measure is reported using G-codes:
CPT E/M codes, CPT service codes and HCPCS G-codes are used to identify patients who are
included in the measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
A qualified e-Prescribing system has been adopted capable of generating a medication list and
selecting/printing/transmitting/performing safety checks of prescriptions
Definitions:
Qualified e-Prescribing system – an e-Prescribing system that is capable of ALL of the
following:
• Generating a complete active medication list incorporating electronic data received
from applicable pharmacy drug plan(s) if available
• Selecting medications, printing prescriptions, electronically transmitting prescriptions,
and conducting all safety checks (defined below)
• Providing information related to the availability of lower cost, therapeutically
appropriate alternatives (if any)
• Providing information on formulary or tiered formulary medications, patient eligibility,
and authorization requirements received electronically from the patient’s drug plan
e-Prescribing – Entering a prescription for a medication into an automated data entry
system that generates a prescription electronically instead of handwriting the prescription
on paper

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Safety checks – Automated prompts that offer the provider information on the drug being
prescribed, potentially inappropriate dose or route of administration of a drug, drug-drug
interactions, allergy concerns, or warnings and cautions
Numerator Coding:
Prescriptions Generated via Qualified e-Prescribing System
G8443: All prescriptions created during the encounter were generated using a qualified ePrescribing system
OR

Qualified e-Prescribing System Available, Prescription(s) not Generated or not
Generated Via Qualified e-Prescribing System for System/Patient Reasons
G8445: No prescriptions were generated during the encounter. Provider does have access
to a qualified e-Prescribing system
OR
G8446: Some or all prescriptions generated during the encounter were handwritten or
phoned in due to one of the following: required by state law, patient request, or qualified ePrescribing system being temporarily inoperable

DENOMINATOR:
All patients aged 18 years and older
Denominator Coding:
A CPT service code, CPT E/M code, or G-code is required to identify patients for
denominator inclusion.
CPT service codes, CPT E/M codes, or HCPCS G-codes: 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201,
99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243,
99244, 99245, G0101, G0108, G0109
RATIONALE:
Automation of the ambulatory prescribing process has many potential benefits including:
• Patient safety through computerized transmission of legible prescriptions directly to the
pharmacy and checks for harmful interactions.
• Patient satisfaction in a process that results in fewer errors and less waiting time
• Avoidance of unnecessary phone calls for clarification between Providers and
Pharmacies.
• Easier data collection of physician prescribing patterns and improved formulary
compliance for Health plans, pharmacy benefit managers and employers.
Evidence Supporting the Criterion of the Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: reduction of adverse drug events, reduction of unnecessary utilization, and
improved patient safety, but not consistently high quality evidence

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Corley, S. T. (2003). "Electronic prescribing: a review of costs and benefits." Topics in Health
Information Management 24(1): 29-38.
Corley estimated cost savings from reduction of adverse drug events following
implementation of electronic prescribing.
Study quality level 2 (limited-quality patient-oriented evidence)
Hillestad, R., et al. (2005). "Can electronic medical record systems transform health care?
Potential health benefits, savings and costs." Health Affairs 24(5): 1103-1117.
This article concludes that two-thirds of the approximately 8 million adverse drug events
that occur in the outpatient setting would be avoided through the widespread use of
computerized order entry (CPOE).
Study quality level 2 (limited-quality patient-oriented evidence)
Kohn, L., et al. (1999). To err is human: Building a safer health system. Washington, D.C., National
Academy Press.
This report concluded, from a case analysis, that there is supporting evidence to show that
adverse drug events (ADE) resulted in an increase in physician office and emergency
department visits, and of those physician office visits, more than 50% were “judged to be
unnecessary and potentially avoidable.” Additionally, the report stated, “Physicians do not
routinely screen for potential drug interactions, even when medication history information is
readily available.”
Study quality level 2 (limited-quality patient-oriented evidence)
Middleton, B. (2005). The value of health information technology in clinical practice. Pennsylvania
eHealth Initiative, Harrisburg.
Dr. Middleton discusses the value of ambulatory computerized order entry (ACPOE). A
model was developed based on data derived from HIT implementation in the Partners
Healthcare System. When applied nationally, this model predicts a potential savings of $44
billion and the prevention of 2 million adverse drug events per year.
Study quality level 2 (limited-quality patient-oriented evidence)
Shekelle, P., Morton, S., Keeler, E. (2006). Costs and benefits of health information technology.
Evidence Report/Technology Assessment, AHRQ. 132.
Electronic prescribing is widely believed to improve accuracy of the prescription process
and thereby reduce potential for medical errors and increase health care quality. Shekelle
et al. observe that EMRs with electronic prescribing improve patient safety by reducing
adverse drug events in the inpatient setting.
Study quality level 2 (limited-quality patient-oriented evidence)

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Measure #126: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological
Evaluation
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a
neurological examination of their lower extremities
INSTRUCTIONS:
This measure is to reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. This measure may be reported by non-MD/DO clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
This measure is reported using G-codes:
ICD-9 diagnosis codes, CPT codes, and patient demographics (age, gender, etc.) are used to
identify patients who are included in the measure’s denominator. G-codes are used to report the
numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who had a lower extremity neurological exam performed at least once within 12 months
Definition: A lower extremity neurological exam consists of a documented evaluation of
motor and sensory abilities including reflexes, vibratory, proprioception, sharp/dull and
5.07 filament detection.

OR

OR

Numerator Coding:
Lower Extremity Neurological Exam Performed
G8404: Lower extremity neurological exam performed and documented
Lower Extremity Neurological Exam not Performed for Documented Reasons
G8406: Clinician documented that patient was not an eligible candidate for lower extremity
neurological exam measure
Lower Extremity Neurological Exam not Performed
G8405: Lower extremity neurological exam not performed

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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetes mellitus
Denominator Coding:
An ICD-9 diagnosis code for diabetes mellitus and a CPT code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93
AND
CPT codes: 10060, 10061, 10180, 11000, 11040, 11041, 11042, 11043, 11044, 11055,
11056, 11057, 11719, 11720, 11721, 11730, 11740, 97001, 97002, 99201, 99202, 99203,
99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308,
99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341,
99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Foot ulceration is the most common single precursor to lower extremity amputations among
persons with diabetes. Treatment of infected foot wounds accounts for up to one-quarter of all
inpatient hospital admissions for people with diabetes in the United States. Peripheral sensory
neuropathy in the absence of perceived trauma is the primary factor leading to diabetic foot
ulcerations. Approximately 45-60% of all diabetic ulcerations are purely neuropathic. Other forms of
neuropathy may also play a role in foot ulcerations. Motor neuropathy resulting in anterior crural
muscle atrophy or intrinsic muscle wasting can lead to foot deformities such as foot drop, equinus,
and hammertoes. In people with diabetes, 22.8% have foot problems -- such as amputations and
numbness -- compared with 10% of nondiabetics. Over the age of 40 years old, 30% of people with
diabetes have loss of sensation in their feet.
CLINCAL RECOMMENDATION STATEMENTS:
Recognizing important risk factors and making a logical, treatment-oriented assessment of the
diabetic foot requires a consistent and thorough diagnostic approach using a common language.
Without such a method, the practitioner is more likely to overlook vital information and to pay
inordinate attention to less critical points in the evaluation. A useful examination will involve
identification of key risk factors and assignment into appropriate risk category. Only then can an
effective treatment plan be designed and implemented. (ACFAS/ACFAOM Clinical Practice
Guidelines)

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Measure #127: Diabetic Foot and Ankle Care, Ulcer Prevention: Evaluation of Footwear
DESCRIPTION:
Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were
evaluated for proper footwear and sizing
INSTRUCTIONS:
This measure is to reported a minimum of once per reporting period for patients with diabetes
mellitus seen during the reporting period. This measure may be reported by non-MD/DO clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding.
This measure is reported using G-codes:
ICD-9 diagnosis codes, CPT E/M service codes, CPT procedure codes, and patient demographics
(age, gender, etc.) are used to identify patients who are included in the measure’s denominator. Gcodes are used to report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients who were evaluated for proper footwear and sizing at least once within 12 months
Definition: Evaluation for proper footwear includes a foot examination documenting the
vascular, neurological, dermatological, and structural/biomechanical findings. The foot
should be measured using a standard measuring device and counseling on appropriate
footwear should be based on risk categorization.
Numerator Coding:
Footwear Evaluation Performed
G8410: Footwear evaluation performed and documented
OR

OR

Footwear Evaluation not Performed for Documented Reasons
G8416: Clinician documented that patient was not an eligible candidate for footwear
evaluation measure
Footwear Evaluation not Performed
G8415: Footwear evaluation was not performed

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DENOMINATOR:
All patients aged 18 years and older with a diagnosis of diabetes mellitus
Denominator Coding:
An ICD-9 diagnosis code for diabetes mellitus and a CPT code are required to identify
patients for denominator inclusion.
ICD-9 diagnosis codes: 250.00, 250.01, 250.02, 250.03, 250.10, 250.11, 250.12, 250.13,
250.20, 250.21, 250.22, 250.23, 250.30, 250.31, 250.32, 250.33, 250.40, 250.41, 250.42,
250.43, 250.50, 250.51, 250.52, 250.53, 250.60, 250.61, 250.62, 250.63, 250.70, 250.71,
250.72, 250.73, 250.80, 250.81, 250.82, 250.83, 250.90, 250.91, 250.92, 250.93
AND
CPT codes: 10060, 10061, 10180, 11000, 11040, 11041, 11042, 11043, 11044, 11055,
11056, 11057, 11719, 11720, 11721, 11730, 11740, 97001, 97002, 99201, 99202, 99203,
99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308,
99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341,
99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
RATIONALE:
Foot ulceration is the most common single precursor to lower extremity amputations among
persons with diabetes. Shoe trauma, in concert with loss of protective sensation and concomitant
foot deformity, is the leading event precipitating foot ulceration in persons with diabetes. Treatment
of infected foot wounds accounts for up to one-quarter of all inpatient hospital admissions for
people with diabetes in the United States. Peripheral sensory neuropathy in the absence of
perceived trauma is the primary factor leading to diabetic foot ulcerations. Approximately 45-60%
of all diabetic ulcerations are purely neuropathic. In people with diabetes, 22.8% have foot
problems -- such as amputations and numbness -- compared with 10% of nondiabetics. Over the
age of 40 years old, 30% of people with diabetes have loss of sensation in their feet.
CLINCAL RECOMMENDATION STATEMENTS:
The multifactorial etiology of diabetic foot ulcers is evidenced by the numerous pathophysiologic
pathways that can potentially lead to this disorder. Among these are two common mechanisms by
which foot deformity and neuropathy may induce skin breakdown in persons with diabetes. The
first mechanism of injury refers to prolonged low pressure over a bony prominence (i.e., bunion or
hammertoe deformity). This generally causes wounds over the medial, lateral, and dorsal aspects
of the forefoot and is associated with tight or ill-fitting shoes. (ACFAS/ACFAOM Clinical Practice
Guidelines)

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Measure #128: Universal Weight Screening and Follow-Up
DESCRIPTION:
Percentage of patients aged 65 years and older with a calculated Body Mass Index (BMI) within
the past six months or during the current visit that is documented in the medical record and if the
most recent BMI is ≥ 30 or < 22, a follow-up plan is documented
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. The most recent quality code submitted will be used for performance calculation.
There is no diagnosis associated with this measure. This measure may be reported by clinicians
who perform the quality actions described in the measure based on the services provided and the
measure-specific denominator coding. BMI measured and documented in the medical record may
be reported if done in the provider’s office/facility or if BMI calculation within the past six months is
documented in outside medical records obtained by the provider. The documentation of a follow up
plan should be based on the most recently calculated BMI.
This measure is reported using G-codes:
CPT procedure codes, CPT E/M codes, CPT service codes, HCPCS D-codes, HCPCS G-codes,
and patient demographics (age, gender, etc.) are used to identify patients who are included in the
measure’s denominator. G-codes are used to report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients with BMI calculated within the past six months or during the current visit and a follow up
plan documented if the BMI is ≥ 30 or < 22
Definitions:
BMI – Body Mass Index (BMI) is a number calculated from a person’s weight and height.
BMI provides a reliable indicator of body fatness for most people and is used to screen for
weight categories that may lead to health problems. BMI is calculated by dividing a
person’s weight (in kilograms) by his/her height (in meters, squared). BMI can also be
calculated by multiplying weight (in pounds) by 705, then dividing by height (in inches)
twice. A simpler method to calculate the BMI involves the use of a chart. The weight is
plotted on one axis and the height is plotted on the other axis. The BMI can then be read
where the two points intersect. Example BMI charts are widely available via the internet.
Calculated BMI – Requires that both the height and weight are actually measured. Values
merely reported by the patient cannot be used.
Follow-up plan – Proposed outline of treatment to be conducted as a result of abnormal
BMI measurement. Such follow-up can include documentation of a future appointment,
education, referral, prescription/administration of medications/dietary supplements, etc.
Not eligible for BMI measurement – Patients can be considered not eligible in the
following situations:

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•
•
•
•
•

If the patient already is diagnosed as over or under weight and there is documentation
in the medical record that the weight problem is being managed by another provider
If the patient has a terminal illness
If the patient refuses BMI measurement
If there is any other reason documented in the medical record by the provider
explaining why BMI measurement was not appropriate
Patient is in an urgent or emergent medical situation where time is of the essence and
to delay treatment would jeopardize the patient’s health status

Numerator Coding:
BMI Calculated, No Follow-up Plan Needed or BMI Calculated, Follow-up Plan
Documented
G8420: BMI < 30 AND ≥ 22 was calculated and documented
OR
G8417: BMI ≥ 30 was calculated and a follow-up plan was documented in the medical
record
OR
G8418: BMI < 22 was calculated and a follow-up plan was documented in the medical
record
OR
OR

Patient not Eligible for BMI Calculation for Documented Reasons
G8422: Patient not eligible for BMI calculation
BMI not Performed and/or Calculated BMI ≥ 30 or < 22, Follow-up Plan not
Documented, Reason not Specified
G8421: BMI not calculated
OR
G8419: BMI ≥ 30 OR < 22 was calculated, but no follow-up plan documented in the
medical record

DENOMINATOR:
Patients aged 65 years and older
Denominator Coding:
A CPT procedure code, CPT service code, CPT E/M code, HCPCS D-code or HCPCS Gcode is required to identify patients for denominator inclusion.
CPT procedure codes, CPT service codes, CPT E/M codes, HCPCS D-codes or
HCPCS G-codes: 00140, 00142, 00170, 00400, 00402, 00810, 00832, 00851, 00910,
00920, 01380, 01382, 01400, 01732, 01810, 01820, 01829, 90801, 90802, 90804, 90805,
90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 97001, 97003, 97802, 97803,
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242,
99243, 99244, 99245, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337,
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, D7140, D7210,
G0101, G0108, G0270

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RATIONALE:
Of the Medicare population, 37 percent are overweight and 18 percent are obese, the economic
impact of which has been estimated at $117 billion in the U.S. Additionally, elderly patients with
unintentional weight loss are at higher risk for infection, depression and death. Older people have
special nutritional needs due to age and disease processes and professionals of all disciplines
need to help older individuals modify their nutritional status, thereby improving quality of life
(American Dietetic Association, Nutrition Screening Initiative, 2002).
CLINICAL RECOMMENDATION STATEMENTS:
The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive
counseling and behavioral interventions to promote sustained weight loss for obese adults. (Level
of Evidence = B, USPSTF)
The clinical guideline for obesity recommends assessment of BMI at each encounter (National
Heart, Lung and Blood Institute).
Validated measure of nutrition status serves as an indicator of over-nourishment and undernourishment. Nutrition Screening Initiative: “Nutrition Interventions Manual for Professionals Caring
for Older Americans,” 2002 (Co-sponsored by American Dietetic Association (ADA), AAFP and
National Council on Aging, Inc.).
The NSI-suggested BMI range is 22-27 (values outside this range indicate overweight or
underweight for elderly) Nutrition Screening Initiative: “Nutrition Interventions Manual for
Professionals Caring for Older Americans,” 2002 (Co-sponsored by American Dietetic Association
(ADA), AAFP and National Council on Aging, Inc.).
Interventions can be grouped into six primary categories: Social Services, Oral Health, Mental
Health, Medication Use, Nutritional Education and Counseling, and Nutritional Support. For further
detail on any of the potential interventional strategies, see the Nutritional Interventions Manual for
Professionals Caring for Older Americans, 2002. Nutrition Screening Initiative: “Nutrition
Interventions Manual for Professionals Caring for Older Americans,” 2002 (Co-sponsored by
American Dietetic Association (ADA), AAFP and National Council on Aging, Inc.).
Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: improved clinical outcomes, including improved blood pressure, lipid levels, and
glucose metabolism, decreased diabetes incidence, and reduced mortality, but not consistently
high quality evidence
Callee, E. E., Thun, M.J., Petrelli, J.M., Rodriquez, C., Heath, C.W., Jr. (1999). “Body-mass index
and mortality in a prospective cohort of U.S. adults.” New England Journal of Medicine 341: 10971105.
BMI of less than 22 kg per m2 in women and less than 23.5 kg per m2 in men is associated
with increased mortality.
Study quality level 2 (limited-quality patient-oriented evidence)

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Corrada, M. M., et al. (2006). “Association of body mass index and weight change with all-cause
mortality in the elderly.” American Journal of Epidemiology 163(10): 938-949.
The study explored the relation of BMI and weight change to all-cause mortality in the
elderly. Results highlight the influence on older-age mortality risk of being underweight or
obese later in life.
Study quality level 2 (limited-quality patient-oriented evidence)
Flegal, K. M., et al. (2005). “Excess deaths associated with underweight, overweight, and obesity.”
JAMA 293: 1861-1867.
This study sought to estimate deaths associated with underweight (BMI < 18.5),
overweight (BMI 25 to < 30), and obesity (BMI ≥ 30) in the United States in 2000.
Underweight was associated with 33,746 excess deaths. Underweight and obesity,
particularly higher levels of obesity, were associated with increased mortality relative to the
normal weight category.
Study quality level 2 (limited-quality patient-oriented evidence)
Jain, M. G., et al. (2005). “Body mass index and mortality in women: Follow-up of the Canadian
national breast screening study cohort.” International Journal of Obesity 29: 792-797.
A study designed to examine the relationship between obesity and all-cause mortality in
women confirms the association of high BMI with increased all-cause mortality in women.
Study quality level 2 (limited-quality patient-oriented evidence)
McTigue, K. M., et al. (2003). “Screening and interventions for obesity in adults: Summary of the
evidence for the U.S. preventive services task force.” Annals of Internal Medicine 139(11): 933949.
This meta-analysis concludes that counseling and pharmacotherapy can promote modest
sustained weight loss, improving clinical outcomes. Weight reduction improved blood
pressure, lipid levels, and glucose metabolism and decreased diabetes incidence.
Study quality level 1 (good-quality patient-oriented evidence)

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Measure #129: Universal Influenza Vaccine Screening and Counseling
DESCRIPTION:
Percentage of patients aged 50 years and older who were screened and counseled about the
influenza vaccine during the months of January, February, March, October, November, and
December
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the months of January, February,
March, October, November, and December during the reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure may be
reported by non-MD/DO clinicians who perform the quality actions described in the measure based
on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT E/M codes, CPT service codes, CPT procedure codes, HCPCS G-codes, and patient
demographics (age, gender, etc.) are used to identify patients who are included in the measure’s
denominator. G-codes are used to report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patients screened and counseled about the influenza vaccine
Definitions:
Screening – Testing done on people at risk of developing a certain disease, even if they
have no symptoms. Screening tests can predict the likelihood of someone having or
developing a particular disease. This measure looks for the test being done in the
practitioner’s office that is filing the code.
Counseling – Providing information or advice related to the applicable measure such as
including ways to stay healthy, implementing lifestyle modifications, and/or improving
health status. In this measure, the advice constitutes recommendation to receive vaccine
unless contraindicated. Additional information on flu vaccines can be accessed {
HYPERLINK "at" } the CDC website.

OR

Numerator Coding:
Influenza Vaccine Screening Performed, Status Current or Counseling Provided
G8423: Documented that patient was screened and either influenza vaccination status is
current or patient was counseled
Influenza Vaccine Screening and/or Counseling not Performed, Patient not
Appropriate
G8426: Documented that patient was not appropriate for screening and/or counseling
about the influenza vaccine (e.g., allergy to eggs)

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OR

Influenza Vaccine Screening not Performed and/or Counseling not Provided, Reason
not Specified
G8424: Influenza vaccine status was not screened
OR
G8425: Influenza vaccine status screened, patient not current and counseling was not
provided

DENOMINATOR:
Patients aged 50 years and older and dates of service in January, February, March, October,
November, and December
Denominator Coding:
A CPT procedure code, CPT service code, CPT E/M code, or HCPCS G-code is required
to identify patients for denominator inclusion.
CPT procedure codes, CPT service codes, CPT E/M codes, or HCPCS G-codes:
00140, 00142, 00170, 00400, 00402, 00810, 00832, 00851, 00910, 00920, 01380, 01382,
01400, 01732, 01810, 01820, 01829, 97802, 97803, 99201, 99202, 99203, 99204, 99205,
99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, 99324, 99325,
99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345,
99347, 99348, 99349, 99350, G0101, G0108, G0270
RATIONALE:
In the United States, epidemics of influenza typically occur during the winter months and have
been associated with an average of approximately 36,000 deaths per year during 1990-1999. The
CDC reported that although the target coverage set by Healthy People 2010 is 90 percent for
annual influenza immunization, in 2002 national statistics demonstrated rates of only 66 percent.
This measure focuses on the CDC’s Advisory Committee on Immunization Practices (ACIP)
revised recommendation of annual influenza vaccination for all persons age 50 and over, with a
reminder to providers that they should routinely offer influenza vaccine to patients throughout the
influenza season. (see MMWR 2006 citation below)
CLINICAL RECOMMENDATION STATEMENTS:
ACIP recommends annual influenza vaccination for persons aged 50 or older.
In order not to duplicate resources, the task force did not update their 1996 immunization
recommendations and cites the CDC recommendations above, noting that ACIP’s methods used to
review evidence may differ from those used by USPSTF.
Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: improved immunization rates, and decreased morbidity and mortality associated
with influenza, but not consistently high quality evidence

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Ashby-Hughes, B., et al. (1999). "Provider endorsement: The strongest cue in prompting high-risk
adults to receive influenza and pneumococcal immunizations." Clinical Excellence for Nurse
Practitioners 3(2): 97 - 104.
Provider recommendation was the most important reason adults received immunization.
This study suggests that practitioner endorsement can significantly decrease the morbidity
and mortality associated with flu and pneumonia by improving immunization rates.
Study quality level 2 (limited-quality patient-oriented evidence)
CDC (2006). "Prevention and control of influenza: Recommendations of the advisory committee on
immunization practices (ACIP)." MMWR 55(RR10): 1 - 42.
Includes recommendations for administration for annual influenza vaccine for persons age
50 and older. Reminds providers that they should routinely offer influenza vaccine through
the influenza season.
Study quality level 2 (limited-quality patient-oriented evidence)
Mayo, A. M., Cobler, S. (2004). "Flu vaccines and patient decision-making: What we need to
know." Journal of American Academy of Nurse Practitioners 16(9): 402-410.
Recommending flu vaccine, offering vaccine in convenient locations free of charge, and
discussing perceived barriers with patients may increase vaccinations among high-risk
patients.
Study quality level 2 (limited-quality patient-oriented evidence)
Nichol, K. L., et al. (1996). "Factors associated with influenza and pneumococcal vaccination
behavior among high-risk adults." Journal of Geriatric Internal Medicine 11: 673-677.
Emphasis on provider recommendations and the knowledge and attitudes of patients may
enhance flu and pneumococcal vaccination rates, even in the context of organized
vaccination programs.
Study quality level 2 (limited-quality patient-oriented evidence)
Postema, A. S., et al. (2000). "Adult immunization programs in nontraditional settings: Quality
standards and guidance for program evaluation." MMWR Recommendation Report 49(RR-1): 1 13.
This report from CDC’s National Vaccine Advisory Committee recognizes that
immunization programs in nontraditional settings might enhance the capacity of the health
care system to effectively deliver vaccine to adults by increasing the number and types of
sites where adults can receive vaccine
Study quality level 2 (limited-quality patient-oriented evidence)

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Measure #130: Universal Documentation and Verification of Current Medications in the
Medical Record
DESCRIPTION:
Percentage of patients aged 18 years and older with written provider documentation that current
medications with dosages (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary
[nutritional] supplements) were verified with the patient or authorized representative
INSTRUCTIONS:
This measure is to be reported at each visit occurring during the reporting period for patients seen
during the reporting period. There is no diagnosis associated with this measure. This measure may
be reported by non-MD/DO clinicians who perform the quality actions described in the measure
based on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT service codes, CPT procedure codes, HCPCS G-codes and patient demographics (age,
gender, etc.) are used to identify patients who are included in the measure’s denominator. G-codes
are used to report the numerator of the measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Verification of patient’s current medications with dosages is documented
Definitions:
Authorized representative – A person who is acting on the patient’s behalf and who does
not have a conflict of interest with the patient, when the patient is temporarily or
permanently unable to act for himself or herself. This person should have the patient’s best
interests at heart and should be reasonably expected to act in a manner that is protective
of the person and the rights of the patient. Preferably, this individual is appointed by the
patient.
Not eligible – A patient is not eligible if one or more of the following condition(s) exist:
• Patient refuses to participate
• Patient is in an urgent or emergent medical situation where time is of the essence and
to delay treatment would jeopardize the patient’s health status
• Patient cognitively impaired and no authorized representative available
Current medications – All medications (includes prescription, over-the-counter, herbals,
vitamin/mineral/dietary [nutritional] supplements) a patient may be taking routinely and/or
on a PRN basis

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Numerator Coding:
Current Medication Verification Documented
G8427: Written provider documentation was obtained confirming that current medications
with dosages (includes prescription, over-the-counter, herbals, vitamin/mineral/dietary
[nutritional] supplements) were verified with the patient or authorized representative or
patient assessed and is not currently on any medications.
OR
OR

Current Medications not Documented, Patient not Eligible
G8430: Documentation that patient is not eligible for medication assessment
Current Medications not Documented and/or Patient Verification not Documented,
Reason not Specified
G8428: Current medications with dosages (includes prescription, over-the-counter,
herbals, vitamin/mineral/dietary [nutritional] supplements) were documented without
documented patient verification
OR
G8429: Incomplete or no documentation that patient’s current medications with dosages
(includes prescription, over-the-counter, herbals, vitamin/mineral/dietary [nutritional]
supplements) were assessed

DENOMINATOR:
Patients aged 18 years and older
Denominator Coding:
A CPT procedure code, CPT service code, or HCPCS G-code is required to identify
patients for denominator inclusion.
CPT procedure codes, CPT service codes, or HCPCS G-codes: 00140, 00142, 00170,
00400, 00402, 00810, 00832, 00851, 00910, 00920, 01380, 01382, 01400, 01732, 01810,
01820, 01829, 90801, 90802, 96116, 96150, 96152, 97001, 97002, 97003, 97004, 97802,
97803, G0101, G0108, G0270
RATIONALE:
Adverse drug events (ADEs) are one of the leading causes of hospitalizations and deaths in the
U.S., with 13% of ADEs occurring in patients with a prior or documented allergy/reaction to the
reactive drug. Using a medication list in the office setting promotes patient safety and reduces
medical errors, both by improving documentation in general and, specifically, by improving
communication between patients and providers.
CLINICAL RECOMMENDATION STATEMENTS:
In addition, as part of its efforts to promote patient safety and reduce the growing incidence of
medical errors in the office setting, the Institute for Healthcare Improvement created a
recommended medication list for patients and their families to carry with them to medical
appointments to help providers reconcile medications during medical visits. Refer to: Institute for
Healthcare Improvement, Medication List For Patients and Families, and Massachusetts Coalition
for the Prevention of Medical Error (in collaboration with the Massachusetts Medical Society). ]

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Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: improved patient safety, reduced adverse drug events, reduced hospitalizations
and death, and reduced costs, but not consistently high quality evidence
Ghandi, T., et al. (2000). "Drug complications in outpatients." Journal of General Internal Medicine
15: 149-154.
A total of 75% of office visits to primary care providers involve the initiation or continuation
of drug therapy and estimates of the proportion of outpatients experiencing an ADE per
year range from 5-35%, with 13% of events occurring in patients with a prior or
documented allergy/reaction to the causative drug. There is need for improved physicianpatient communication and documentation of medications in the outpatient setting.
Study quality level 2 (limited-quality patient-oriented evidence)
Gurwitz, J., et al. (2003). "Incidence and preventability of adverse drug events among older
persons in the ambulatory setting." JAMA 289: 1107-1116.
ADEs were identified as one of the most serious concerns regarding medication use in
older persons cared for in the ambulatory setting. The authors recommend prevention
strategies that target the prescribing and monitoring stages of pharmaceutical care and
interventions focused on improving patient compliance and monitoring of prescribed
medications.
Study quality level 2 (limited-quality patient-oriented evidence)
Kaufman, D., et al. (2002). "Recent patterns of medication use in the ambulatory adult population
of the United States." JAMA 287: 337 - 344.
ADEs are among the leading cause of hospitalizations and death in the U.S. The
substantial overlap between use of prescription medicine and use of herbals/supplements
raises concerns about unintended interactions. Therefore, the authors recommend
documentation of usage patterns to provide a basis for improving the safety of medication
use.
Study quality level 2 (limited-quality patient-oriented evidence)
Simmonds, M. (2000). "Anesthetists' records of pre-operative assessment." Clinical Performance
and Quality Health Care 8(1): 22-27.
Previous anesthesia, drug history, and allergies were recorded in only one to two-thirds of
patient charts, thus identifying this as an opportunity for improvement, given the safety and
subsequent cost implications.
Study quality level 2 (limited-quality patient-oriented evidence)
Wilson, I. B., et al. (2007). "Physician-patient communication about prescription medications nonadherence." Journal of General Internal Medicine 22(1).
There is a wide communication gap between physicians and elderly patients: one-third of
all seniors surveyed and 24% of those with three or more chronic conditions did not talk to
their doctors about all of their medicines in the past 12 months.
Study quality level 2 (limited-quality patient-oriented evidence)

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12/31/2007

Measure #131: Pain Assessment Prior to Initiation of Patient Treatment
DESCRIPTION:
Percentage of patients aged 18 years and older with documentation of a pain assessment (if pain
is present, including location, intensity and description) through discussion with the patient or
through use of a standardized tool on each initial evaluation prior to initiation of therapy
INSTRUCTIONS:
This measure is to be reported for each initial evaluation occurring during the reporting period for
patients seen during the reporting period. There is no diagnosis associated with this measure. This
measure may be reported by non-MD/DO clinicians who perform the quality actions described in
the measure based on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT service codes and patient demographics (age, gender, etc.) are used to identify patients who
are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patient’s pain assessment prior to initiation of treatment is documented
Definitions:
Standardized tool – A standardized tool is a test or measure administered and scored in
a consistent manner and supported by psychometric literature. Examples of tools for pain
assessment include, but are not limited to, Multidimensional Pain Score and McGill Pain
Questionnaire.
Not eligible – A patient is not eligible if the following condition(s) exist:
• Patient refuses to participate
• Severe mental and/or physical incapacity where the person is unable to express
himself/herself in a manner understood by others. For example, cases where pain
cannot be accurately assessed through use of nationally recognized standardized pain
assessment tools
• Situations where the patient’s motivation to improve may impact the accuracy of
results of nationally recognized standardized pain assessment tools
• Patient is in an urgent or emergent situation where time is of the essence and to delay
treatment would jeopardize the patient’s health status
Numerator Coding:
Pain Assessment Documented
G8440: Documentation of pain assessment (including location, intensity and description)
prior to initiation of treatment or documentation of the absence of pain as a result of
assessment

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OR
OR

Pain Assessment not Documented, Patient not Eligible
G8442: Documentation that patient is not eligible for pain assessment
Pain Assessment not Documented, Reason not Specified
G8441: No documentation of pain assessment (including location, intensity and
description) prior to initiation of treatment

DENOMINATOR:
Patients aged 18 years and older
Denominator Coding:
A CPT service code is required to identify patients for denominator inclusion.
CPT service codes: 90801, 90802, 96116, 96150, 97001, 97003, 98940, 98941, 98942
RATIONALE:
The multidisciplinary pain management team is the optimal method for delivery of comprehensive
treatment to patients in pain. Thus, it is essential for therapists to assess pain prior to initiation of
therapy. Pain is the most common symptom for which the general population seeks health care,
with chronic pain costing the U.S. $100 billion per year in lost worker productivity and health costs.
CLINICAL RECOMMENDATION STATEMENTS:
The Institute for Clinical Systems Improvement (ICSI) supports that the intensity of pain should be
assessed prior to the initiation of appropriate treatment and continually reassessed throughout the
duration of treatment.
Reducing the intensity of the pain by just 25% has been shown to achieve a 50% improvement in
functional status (Flor, Fydrich, & Turk, 1992. Evidence Grade = A).
Older adults with persistent pain commonly experience an increase in pain intensity with movement
and, as a result, will limit the activities or movements that exacerbate the pain (e.g., stair climbing
or walking) (Davis, Hiemenz, & White, 2002; Duong et al., 2005. Evidence Grade = C).
A multidisciplinary approach to diagnosis and treatment of pain is the preferred method of
delivering health care to patients with chronic pain of any etiology due to the complexity of
diagnosis and management. (International Association for the Study of Pain (IASP). Task Force on
Guidelines for Desirable Characteristics for Pain Treatment Facilities, Level N/A).
Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: improved diagnosis and treatment, improved pain management, and improved
outcomes, but not consistently high quality evidence
Bloch, R. (2004). "Rehabilitation medicine approach to cancer pain." Cancer Investigation 22(6):
944-948.
Treatment of cancer pain may benefit from interventions focusing on function and physical
and occupational therapy may all be needed to help manage cancer pain, especially

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insofar as pain may result not only from the cancer itself but also from immobility and
debilitation. Therefore assessment of the patient is important in addressing the source of
pain.
Study quality level 2 (limited-quality patient-oriented evidence)
Loeser, J. D. (2007). "Task force on guidelines for desirable characteristics for pain treatment
facilities." Retrieved May 16, 2007 from the IASP website.
The task force on guidelines for desirable characteristics for pain treatment facilities
recommends the multidisciplinary approach to diagnosis and treatment as the preferred
method of delivering health care to patients with chronic pain of any etiology. It further
recommends evaluation and treatment by non-medical health care providers, i.e.,
therapists, given that medical treatments have already failed many patients in pain.
Study quality level 2 (limited-quality patient-oriented evidence)
Schunk, C., et al. (2000). "Pain outcomes: Measurement and application to the American physical
therapy association guide to physical therapy practice." Orthopaedic Physical Therapy Clinics of
North America 9(1): 89 - 97.
Pain is a viable factor in physical therapy and should be included in outcome
measurement. The American Physical Therapy Association Guide to Physical Therapy
Practice includes the parameter of pain as an element of patient management. The
appropriate tool depends on the practice setting and the patient population served.
Study quality level 2 (limited-quality patient-oriented evidence)
Shannon, E. (2002). "Reflections on clinical practice by occupational therapists working in
multidisciplinary pain management programs in the UK and the USA." Australian Occupational
Therapy Journal 49(1).
All patients with chronic pain should be appropriately evaluated before treatment is
implemented, with a multidisciplinary approach to diagnosis and treatment the preferred
method of delivering health care to patients with chronic pain of any etiology.
Study quality level 2 (limited-quality patient-oriented evidence)
Starke, A. (2005). "Managing the elusive beast of chronic pain: A challenge for PTs." PT magazine:
11.
Pain causes more adult disability than any other condition in the U.S. There are many
components to treatment of chronic pain, assessment being a critical component.
Study quality level 2 (limited-quality patient-oriented evidence)

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Measure #132: Patient Co-Development of Treatment Plan/Plan of Care
DESCRIPTION:
Percentage of patients aged 18 years and older identified as having actively participated in the
development of the treatment plan/plan of care. Appropriate documentation includes signature of
the practitioner and either co-signature of the patient or documented verbal agreement obtained
from the patient or, when necessary, an authorized representative
INSTRUCTIONS:
This measure is to be reported at least one time for each unique episode of care for patients seen
during the reporting period. For the purpose of this measure, a unique episode of care is defined by
the care given for each unique diagnosis (ICD-9 code) during the reporting period. This measure
may be reported by non-MD/DO clinicians who perform the quality actions described in the
measure based on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT service codes and patient demographics (age, gender, etc.) are used to identify patients who
are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patient’s active participation in development of treatment plan/plan of care is documented
Definitions:
Unique episode of care – For the purpose of this measure is defined by each unique
ICD-9 code billed in combination with an appropriate CPT service code during the
reporting period. Multiple diagnoses on a claim form will count as one episode.
Active participation – Patient involvement in discussions, decisions, objectives
determination, and goal setting to the extent that the patient is a co-author of, and
responds affirmatively to, the care plan/treatment plan.
Care plan/treatment plan – A roadmap or course of action involving input and approval
from the patient.
Authorized representative – A person who is acting on the patient’s behalf and who does
not have a conflict of interest with the patient, when the patient is temporarily or
permanently unable to act for himself or herself, but not against the patient’s wishes. This
person should have the patient’s best interests at heart and should be reasonably
expected to act in a manner that is protective of the person and the rights of the patient.
Preferably, this individual is appointed by the patient.
Not eligible – A patient is not eligible if one or more of the following conditions exist:
• Patient refuses to participate.
• Patient is in an urgent or emergent health or crisis situation where time is of the
essence and to delay treatment would jeopardize the patient’s health status.

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•

OR

OR

Episode of care began either prior to or extends beyond reporting period and
Treatment Plan/Plan of Care was co-developed outside reporting period.

Numerator Coding:
Active Participation Documented
G8437: Documentation of clinician and patient involvement with the development of a
treatment plan/plan of care including signature by the practitioner and either a co-signature
by the patient or documented verbal agreement obtained from the patient or, when
necessary, an authorized representative
Active Participation not Documented, Patient not Eligible
G8439: Documentation that patient is not eligible for co-developing a treatment plan/plan
of care including signature by the practitioner and either a co-signature by the patient or
documented verbal agreement obtained from the patient or, when necessary, an
authorized representative
Active Participation not Documented, Reason not Specified
G8438: No documentation of clinician and patient involvement with the development of a
treatment plan/plan of care including signature by the practitioner and either a co-signature
by the patient or documented verbal agreement obtained from the patient or, when
necessary, an authorized representative

DENOMINATOR:
Patients aged 18 years and older
Denominator Coding:
A CPT service code is required to identify patients for denominator inclusion.
CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 96116,
96150, 96151, 96152, 97001, 97002, 97003, 97004, 97802, 97803, G0270
RATIONALE:
Collaborative interventions involving both client and care provider are significantly more acceptable
and likely to produce follow through than directive approaches. This is consistent with the findings
of Ed Wagner’s “The Chronic Care Model,” which states that evidence-based change concepts
foster productive interactions between informed patients who take an active part in their care and
providers with resources and expertise.
CLINICAL RECOMMENDATION STATEMENTS:
The Siskin Hospital for Physical Rehabilitation states that patients’ basic treatment plan and initial
goals should include input and agreement of the patient before treatment begins, while the Scottish
Intercollegiate Guidelines Network (SIGN) suggests that patients and their caregivers should have
an early, active role in the multidisciplinary rehabilitation team.
The Institute for Clinical Systems Improvement (ICSI) recommends that patients and their families
should be educated and actively engaged as to diagnosis, prognosis, and treatment options, while
the National Collaborating Center for Mental Health recommends that health care professionals

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should make all efforts necessary to ensure that a patient can give meaningful and properly
informed consent before treatment is initiated.
The 2005 Standards of Practice for Occupational Therapy recommends in Standard III, 1: An
occupational therapist has overall responsibility for the development, documentation, and
implementation of the occupational therapy intervention based on the evaluation, client goals,
current best evidence, and clinical reasoning (American Occupational Therapy Association).
A 2001 American Psychiatric Association guideline states that treatment of patients with borderline
personality disorders should be a collaborative process between patient and clinician and that
patient preference is an important factor to consider in developing an individual treatment plan
(APA).
The 2004 Department of Defense (DoD) and Department of Veterans Affairs (VHA) guideline
states that treatment options for persons with psychoses should be presented and discussed with
the person/legal guardian and then proceed with treatment if the person/legal guardian consents
(DoD and VHA).
Institute for Clinical Systems Improvement 1995 guideline suggests that providers should
recognize that it is a sign of progress when a patient becomes more ready to change a healthrelated behavior (ICSI).
In a Substance Abuse and Mental Health Services Administration 2005 guideline for substance
abuse treatment for persons with co-occurring disorders, motivational interviewing was cited as
being proven effective in helping clients clarify goals and commit to change (SAMHSA).
Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: e.g., improved treatment outcomes, e.g., improved follow through with
recommendations and improved follow-up percent days abstinent; increased patient satisfaction;
and reduced costs, but not consistently high quality evidence
Amrhein, P. C., et al. (2003). "Client commitment language during motivational interviewing
predicts drug use outcomes." Journal of Consulting and Clinical Psychology 71(862 - 878).
Motivational interview sessions revealed commitment strength language during a change
plan was more common among maintainers and changers and was predictive of follow-up
percent days abstinent.
Study quality level 2 (limited-quality patient-oriented evidence)
Geller, J., et al. (2003). "Collaborative versus directive interventions in the treatment of eating
disorders: Implications for care providers." Professional Psychology: Research and Practice 34:
406 - 413.
Clients and care providers related collaborative interventions as being significantly more
acceptable and likely to produce follow through with recommendations than directive
approaches.
Study quality level 2 (limited-quality patient-oriented evidence)

323

12/31/2007

Ruback, S., et al. (2005). "Motivational interviewing: a systematic review and meta-analysis." The
British Journal of General Practice 55(513): 305 - 312.
Motivational interviewing in a scientific setting outperforms traditional advice giving in the
treatment of a broad range of behavioral problems and diseases.
Study quality level 2 (limited-quality patient-oriented evidence)
Swenson, et al. (2004). "Patient-centered communication: do patients really prefer it?" Journal of
General Internal Medicine 19(11).
A randomized study revealed that 82% of participants < 30 years old, 68% of participants
aged 30-59; 55% of participants aged > 59 preferred patient-centered communication.
Additionally 76% of participants with post-college education, 73% of participants with some
college education, and 49% of participants with a high school education preferred patientcentered communication.
Study quality level 2 (limited-quality patient-oriented evidence)
Wagner, E. H. (1998). "Chronic disease management: What will it take to improve care for chronic
illness?" Effective Clinical Practice 1: 2-4.
The chronic care model identifies the essential elements of a health care system that
encourage high-quality chronic disease care. These elements are the community, the
health system, self-management support, delivery system design, decision support and
clinical information systems. Evidence-based change concepts under each element, in
combination, foster productive interactions between informed patients who take an active
part in their care and providers with resources and expertise. The model can be applied to
a variety of chronic illnesses, health care settings and target populations. The bottom line
is healthier patients, more satisfied providers, and cost savings.
Study quality level 2 (limited-quality patient-oriented evidence)

324

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Measure #133: Screening for Cognitive Impairment
DESCRIPTION:
Percentage of patients aged 65 years and older who have documentation of results of a screening
for cognitive impairment using a standardized tool
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure may be
reported by non-MD/DO clinicians who perform the quality actions described in the measure based
on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT service codes and patient demographics (age, gender, etc.) are used to identify patients who
are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patient’s screening for cognitive impairment is documented
Definitions:
Screening – Testing done on people at risk of developing a certain disease, even if they
have no symptoms. Screening tests can predict the likelihood of someone having or
developing a particular disease. This measure looks for the test being done in the
practitioner’s office that is filing the code.
Standardized tool – An assessment tool that has been appropriately normalized and
validated for the population in which it is used. Some examples of cognitive impairment
screening tools include: Clinical Dementia Rating Scale, Mini Mental Status Examination
(MMSE), Global Deterioration Scale, Short Portable Mental Status Questionnaire, Clock
Drawing Test, Modified MMSE, Mini-Cog, Hopkins Verbal Learning Test, and 7-Minute
Screen.
Cognitive impairment – Impairment of mental activities associated with thinking, learning,
and memory.
Not eligible/not appropriate – A patient is not eligible/not appropriate if one or more of
the following conditions exist:
• Patient refuses to participate
• Patient is in an urgent or emergent situation where time is of the essence and to delay
treatment would jeopardize the patient’s health status
• Patient was referred with a diagnosis of cognitive impairment
• Patient has been participating in on-going treatment with screening of cognitive
impairment in a preceding reporting period
• Patient is not appropriate for cognitive impairment screening due to physical capacity

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Numerator Coding:
Screening for Cognitive Impairment Documented
G8434: Documentation of cognitive impairment screening using a standardized tool
OR

OR

Screening for Cognitive Impairment not Documented, Patient not Eligible/not
Appropriate
G8436: Patient not eligible/not appropriate for cognitive impairment screening
Screening for Cognitive Impairment not Documented, Reason not Specified
G8435: No documentation of cognitive impairment screening using a standardized tool

DENOMINATOR:
Patients aged 65 years and older
Denominator Coding:
A CPT service code is required to identify patients for denominator inclusion.
CPT service codes: 90801, 90802, 96150, 97003
RATIONALE:
As many as 6.8 million people in the U.S. have dementia, and at least 1.8 million of those are
severely affected. The U.S. Preventive Services Task Force (USPSTF) reported that Alzheimer’s
Disease and cerebrovascular ischemia (vascular dementia) are the two most common causes of
dementia, with estimated economic costs of Alzheimer’s Disease (AD) in the U.S. totaling at least
$100 billion annually. The National Institute of Neurological Disorders and Stroke contends that
accurate diagnosis of dementia is important for patients and their families because it allows early
treatment of symptoms.
CLINICAL RECOMMENDATION STATEMENTS:
The American Psychiatric Association (APA) states that the core of the treatment of demented
patients is psychiatric management, through psychiatric, neurological, and general medical
evaluations of the nature and cause of cognitive deficits, while the American Academy of
Neurology (AAN) states there is good evidence to support the use of general cognitive screening
instruments.
Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: improved early detection and initiation of treatment for dementia that may delay
further progression; reduced iatrogenic illness, unnecessary workups driven by vague symptoms,
and inappropriate and costly utilization of hospital and emergency room care; and improved
outcomes, but not consistently high quality evidence
American Academy of Neurology (AAN)
A guideline revised in 2004 includes the identification and monitoring of Mild Cognitive
Impairment (MCI) patients for progression to Alzheimer’s disease. It also states there is
good evidence to support the use of general cognitive screening instruments.

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In a second guideline developed in 2001, it states that general cognitive screening
instruments, which include the Mini Mental Status Exam (MMSE), Kokmen Short Test of
Mental Status, the 7-Minute Screen, or the Memory Impairment Screen, are useful for the
detection of dementia when used in patient populations with an elevated prevalence of
cognitive impairment either due to age or presence of memory dysfunction.
A third guideline developed in 2001 on the early detection of dementia included a review of
the evidence on mild cognitive impairment. It reported that studies indicated that
individuals characterized as being cognitively impaired, but not meeting clinical criteria for
Alzheimer’s disease (mild cognitive impairment), have a high risk of progressing to
dementia or Alzheimer’s disease. It further reported that, if the figures for incident
Alzheimer’s disease from the general population are used, one could see that the rates
range from 0.2% in the 65-69 year age group to 3.9% in the 85-89 year age group. Finally,
it reported that studies of mild cognitive impairment indicate that the rate of progression to
dementia or Alzheimer’s disease is between 6% and 25% per year.
Study quality level 2 (limited-quality patient-oriented evidence)
Geriatric Nursing Academic Institution
This 2003 guideline, developed by a group of nursing experts from across the country as a
part of the Nurses Improving Care for Health System Elders (NICHE) Project, supports the
use of standardized instruments for cognitive testing.
Study quality level 2 (limited-quality patient-oriented evidence)
Chow, T. W. (2001). "Quality indicators for dementia in vulnerable community dwelling and
hospitalized elders." Annals of Internal Medicine 135: 668-676.
A review of 30 quality indicators for dementia resulted in 14 being judged to be valid by the
expert panel process. These included five dealing with dementia screening and diagnosis.
The cognitive and functional screening indicator states that, if a vulnerable elder is
admitted to the hospital or is new to a physician practice, the multidimensional assessment
of cognitive ability and assessment of functional status should be documented because
screening for dementia can lead to early detection and initiation of treatment that may
delay further progression.
Study quality level 2 (limited-quality patient-oriented evidence)
National Chronic Care Consortium (2003). Tools for the early identification, assessment and
treatment for people with Alzheimer's disease and dementia. Bloomington, National Chronic Care
Networks for Alzheimer's Disease initiative.
Dementia is very prevalent among the elderly, but is often overlooked even by skilled
clinicians. Unrecognized dementia may lead to iatrogenic illness, unnecessary workups
driven by vague symptoms, inappropriate and costly utilization of hospital and emergency
room care, and poor outcomes. Improving our ability to recognize dementia is a key first
step toward improving this widespread situation. The Chronic Care Networks for
Alzheimer’s disease early identification process uses two tools to identify people who may
have dementia and should receive a full assessment. These tools include education and
awareness materials/triggers and a family questionnaire.
Study quality level 2 (limited-quality patient-oriented evidence)

327

12/31/2007

Kawas, C. H. (2006). "Alzheimer's and dementia in the oldest-old: A century of challenges."
Current Alzheimer Research 3(5): 411-419.
Alzheimer’s disease (AD) is the most common type of dementia in the U.S. and much of
the world with rates increasing exponentially from age 65. Increases in life expectancy in
the last century have resulted in a large number of people living to old age and will result in
a quadrupling of AD cases by the middle of the century. Preventing or delaying the onset
of AD could have a huge impact in the number of cases expected to develop. The oldestold are the fastest growing segment of the population and are estimated to account for
12% of the population over 65.
Study quality level 2 (limited-quality patient-oriented evidence)

328

12/31/2007

Measure #134: Screening for Clinical Depression
DESCRIPTION:
Percentage of patients aged 18 years and older screened for clinical depression using a
standardized tool
INSTRUCTIONS:
This measure is to be reported a minimum of once per reporting period for patients seen during the
reporting period. There is no diagnosis associated with this measure. This measure may be
reported by non-MD/DO clinicians who perform the quality actions described in the measure based
on the services provided and the measure-specific denominator coding.
This measure is reported using G-codes:
CPT service codes and patient demographics (age, gender, etc.) are used to identify patients who
are included in the measure’s denominator. G-codes are used to report the numerator of the
measure.
When reporting the measure, submit the appropriate denominator code(s) and the appropriate
numerator G-code.
NUMERATOR:
Patient’s screening for clinical depression is documented
Definitions:
Screening – Testing done on people at risk of developing a certain disease, even if they
have no symptoms. Screening tests can predict the likelihood of someone having or
developing a particular disease. This measure looks for the test being done in the
practitioner’s office that is filing the code.
Standardized tool – An assessment tool that has been appropriately normalized and
validated for the population in which it is used. Some examples of depression screening
tools include: Patient Health Questionnaire (PHQ9), Beck Depression Inventory (BDI or
BDI-II), Center for Epidemiologic Studies Depression Scale (CES-D), Depression Scale
(DEPS), Duke Anxiety-Depression Scale (DADS), Geriatric Depression Scale (GDS), GDS
- Short Version, Hopkins Symptom Checklist (HSCL), The Zung Self-Rating Depression
Scale (SDS), and Cornell Scale Screening (this is a screening tool which is used in
situations where the patient has cognitive impairment and is administered through the
caregiver).
Not eligible/not appropriate – A patient is not eligible if one or more of the following
conditions exist:
• Patient refuses to participate
• Patient is in an urgent or emergent situation where time is of the essence and to delay
treatment would jeopardize the patient’s health status
• Situations where the patient’s motivation to improve may impact the accuracy of
results of nationally recognized standardized depression assessment tools. For
example: certain court appointed cases

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•
•
•

Patient was referred with a diagnosis of depression
Patient has been participating in on-going treatment with screening of clinical
depression in a preceding reporting period
Severe mental and/or physical incapacity where the person is unable to express
himself/herself in a manner understood by others. For example: cases such as
delirium or severe cognitive impairment, where depression cannot be accurately
assessed through use of nationally recognized standardized depression assessment
tools

Numerator Coding:
Screening for Clinical Depression Documented
G8431: Documentation of clinical depression screening using a standardized tool
OR
OR

Screening for Clinical Depression not Documented, Patient not Eligible/Appropriate
G8433: Patient not eligible/not appropriate for clinical depression screening
Screening for Clinical Depression not Documented, Reason not Specified
G8432: No documentation of clinical depression screening using a standardized tool

DENOMINATOR:
Patients aged 18 years and older
Denominator Coding:
A CPT service code is required to identify patients for denominator inclusion.
CPT service codes: 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 97003
RATIONALE:
Major depression was the fourth leading cause of worldwide disease in 1990, with estimated direct
and indirect costs to American businesses ranging from $36.2 to $80 billion annually. The U.S.
Preventive Services Task Force compared the effects of integrated recognition and management
depression screening programs with “usual care” in community primary care practices, and the
results showed significantly improved patient outcomes.
CLINICAL RECOMMENDATION STATEMENTS:
USPSTF recommends screening adults for depression in clinical practices that have systems in
place to assure accurate diagnosis, effective treatment, and follow-up. Small benefits have been
observed in studies that simply feed back screening results to clinicians. Larger benefits have been
observed in studies in which the communication of screening results is coordinated with effective
follow-up and treatment. (Evidence: B)
The Canadian Task Force on Preventive Health Care used the rigorous USPSTF 2002 systematic
review to update their recommendations regarding depression screening. The Canadian task force
arrived at the same practice recommendations as USPSTF.

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Evidence Supporting the Criterion of Quality Measure:
Overall Evidence Grading: SORT Strength of Recommendation B: considerable patient-oriented
evidence, i.e., re: improved recognition and diagnosis of depression, and improved depression
outcomes, but not consistently high quality evidence
Ell, K. (2006). "Depression care for the elderly: Reducing barriers to evidence based practice."
Home Health Care Services Quarterly 25: 115 - 148.
This review provides an overview of evidence identifying use of health services for
depression, effective interventions, barriers to depression care, strategies to reduce
barriers, and translating research into practice. There is strong empirical support for
implementing strategies to improve depression care for older adults, and there is recent
encouraging evidence from Medicare data that older adults may be more willing to seek
and accept antidepressant treatment.
Study quality level 2 (limited-quality patient-oriented evidence)
Hickie, I. B., et al. (2002). "Screening for depression in general practice and related medical
settings." The Medical Journal of Australia 177: S111-116.
This meta-analysis included reviews found by searching MEDLINE, Cochrane, and other
databases. It found that screening increases the recognition and diagnosis of depression
and, when integrated with a commitment to provide coordinated and prompt follow-up of
diagnosis and treatment, clinical outcomes are improved.
Study quality level 1 (good quality patient-oriented evidence)
Kirkcaldy, R. D., Tynes, L.L. (2006). "Depression screening in a VA primary care clinic." Psychiatric
Services 57: 1694 - 1696.
In 1998, the U.S. Department of Veterans Affairs (VA) mandated annual depression
screening at all VA primary care clinics. This article reports on an evaluation of the
screening program. Findings establish benchmarks for screening administration.
Study quality level 2 (limited-quality patient-oriented evidence)
Pignone, M. P., et al. (2002). "Screening for depression in adults: A summary of the evidence for
the U.S. preventive services task force." Annals of Internal Medicine 136: 765-776.
This study aims to clarify whether screening adults for depression in primary care settings
improves recognition, treatment, and clinical outcomes. It concludes that, compared with
usual care, screening for depression can improve outcomes, particularly when screening is
coupled with system changes that help ensure adequate treatment and follow-up.
Study quality level 2 (limited-quality patient-oriented evidence)
Sherman, S. E., et al. (2004). "Improving recognition of depression in primary care: A study of
evidence-based quality improvement." Joint Commission Journal on Quality and Patient Safety
30(2).
Implemented at a VA ambulatory care center, this evidence-based QI intervention led to
profound and lasting changes in primary care providers’ recognition of depression or
depressive symptoms.
Study quality level 2 (limited-quality patient-oriented evidence)

331

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Symbol and Copyright Information
The following notice applies to each of the measures that contain an asterisk (

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Physician Performance Measures (Measures) and related data specifications, developed by the American Medical
Association (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium)
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These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not
been tested for all potential applications.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial
purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale,
license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service
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THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
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© 2004-6 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
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The following notice applies to each of the measures that contain a triangle (

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Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
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These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
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not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
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Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
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THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association. All Rights Reserved
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
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members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2006 American Medical Association.

The following notice applies to each of the measures that contain a clover (

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These Physician Performance Measures (Measures) are not clinical guidelines and do not establish a standard of
medical care, and have not been tested for all potential applications.
The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial
purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale,
license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service
that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement
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THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY
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© 2006-7 American Medical Association and American Society of Hematology. All Rights Reserved. Applicable
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Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
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members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
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CPT® contained in the Measures specifications is copyright 2005 American Medical Association. LOINC® copyright
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("NCQA"). These performance measures are not clinical guidelines and do not establish a standard of medical care.
NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that
uses or reports performance measures and NCQA has no liability to anyone who relies on such measures. NCQA holds
a copyright in this measure and can rescind or alter this measure at any time. Users of the measure shall not have the
right to alter, enhance, or otherwise modify the measure and shall not disassemble, recompile, or reverse engineer the
source code or object code relating to the measure. Anyone desiring to use or reproduce the measure without
modification for a noncommercial purpose may do so without obtaining any approval from NCQA. All commercial
uses must be approved by NCQA and are subject to a license at the discretion of NCQA. ©2004 National Committee
for Quality Assurance, all rights reserved.
Performance measures developed by NCQA for CMS may look different from the measures solely created and owned
by NCQA.

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The following notice applies to each of the measures that contain a heart (

) before the title:

Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while
copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health
care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association and American Society of Clinical Oncology. All Rights Reserved.
CPT® Copyright 2006 American Medical Association.
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2006 American Medical Association.

The following notice applies to each of the measures that contain a Yen sign (

) before the title:

Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while
copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health
care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND
© 2007 American Medical Association, American Society of Clinical Oncology, and National Comprehensive Cancer
Network. All Rights Reserved.
CPT® Copyright 2006 American Medical Association

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Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2006 American Medical Association.

The following notice applies to each of the measures that contain a Euro (

) before the title:

Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium
for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by
physicians.
These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any
physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are
not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for
all potential applications. The Consortium encourages the testing and evaluation of its Measures.
Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not
be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while
copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health
care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the
Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or
distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and
American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be
responsible for any use of these Measures.
THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.
© 2007 American Medical Association and College of American Pathologists. All Rights Reserved
Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code
sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its
members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding
contained in the specifications.
THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.
CPT® contained in the Measures specifications is copyright 2006 American Medical Association

The following notice applies to each of the measures that contain a musical note (
These measures are owned by the American Podiatric Medical Association (APMA).

The following notice applies to each of the measures that contain an Omega (
These measures are owned by The Society of Thoracic Surgeons (STS).

) before the title:

) before the title:

The following notice applies to each of the measures that contain a spade ( ) before the title:
These measures were developed by Quality Insights of Pennsylvania as a special project under the Quality Insights'
Medicare Quality Improvement Organization (QIO) contract HHSM-500-2005-PA001C with the Centers for Medicare
& Medicaid Services.. These measures are in the public domain.

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2007 PQRI Measure Specifications Retired Effective January 1, 2008
Measure #
Measure Title
13
Age-Related Macular Degeneration: Age-Related Eye Disease Study (AREDS)
Prescribed/Recommended
15
Cataracts: Assessment of Visual Functional Status
16
Cataracts: Documentation of Pre-Surgical Axial Length, Corneal Power Measurement
and Method of Intraocular Lens Power Calculation
17
Cataracts: Pre-Surgical Dilated Fundus Evaluation
25
Melanoma: Patient Medical History
26
Melanoma: Complete Physical Skin Examination
27
Melanoma: Counseling on Self-Examination
29
Beta-Blocker at Time of Arrival for Acute Myocardial Infarction (AMI)
37
Dialysis Dose in End Stage Renal Disease (ESRD) Patients
38
Hematocrit Level in End Stage Renal Disease (ESRD) Patients
42
Osteoporosis: Counseling for Vitamin D, Calcium Intake, and Exercise
60
Gastroesophageal Reflux Disease (GERD): Assessment for Alarm Symptoms
61
Gastroesophageal Reflux Disease (GERD): Upper Endoscopy for Patients with Alarm
Symptoms
62
Gastroesophageal Reflux Disease (GERD): Biopsy for Barrett’s Esophagus
63
Gastroesophageal Reflux Disease (GERD): Barium Swallow- Inappropriate Use

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