ACO - CMS Web Interface

The CMS Web Interface lets groups, virtual groups, and APM entities of 25 or more eligible clinicians securely submit over the internet.

Denominator

Patients aged 65 years and older with a visit during the measurement period. 

Numerator

Patients who were screened for future fall risk at least once within the measurement period.

Definitions

 

Screening for Future Fall Risk: Assessment of whether an individual has experienced a fall or problems with gait or balance. A specific screening tool is not required for this measure, however potential screening tools include the Morse Fall Scale and the timed Get-Up-And-Go test. 

Fall: 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. 

ACO-13 (Care-2)

Falls: Screening for Future Fall Risk

Measure Description

Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. 

Denominator

Patients aged 65 years and older with a visit during the measurement period. 

Numerator

Patients who were screened for future fall risk at least once within the measurement period.

Definitions

 

Screening for Future Fall Risk: Assessment of whether an individual has experienced a fall or problems with gait or balance. A specific screening tool is not required for this measure, however potential screening tools include the Morse Fall Scale and the timed Get-Up-And-Go test. 

Fall: 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. 

 

ACO-27 (DM-2)

Diabetes: Hemoglobin A1c (HbA1c)

Poor Control (>9%)

Measure Description

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c >9.0% during the measurement period. 

Denominator

Patients 18-75 years of age with diabetes with a visit during the measurement period. 

Numerator

Patients whose most recent HbA1c level (performed during the measurement period) is >9.0%.

Guidance

Patient is numerator compliant if most recent HbA1c level is >9.0%, the most recent HbA1c result is missing, or if there are no HbA1c tests performed and results documented during the measurement period. If the HbA1c test result is in the medical record, the test can be used to determine numerator compliance.

Only patients with a diagnosis of Type 1 or Type 2 diabetes should be included in the denominator of the measure; patients with a diagnosis of secondary diabetes due to another condition should not be included.

 

ACO-28 (HTN-2)

Controlling High Blood Pressure

Measure Description

Percentage of patients 18-85 years of age who had a diagnosis of hypertension overlapping the measurement period and whose most recent blood pressure was adequately controlled (<140/90 mmHg) during the measurement period. 

Denominator

Patients 18-85 years of age who had a visit and a diagnosis of essential hypertension overlapping the measurement period. 

Numerator

Patients whose most recent blood pressure is adequately controlled (systolic blood pressure <140 mmHg and diastolic blood pressure <90 mmHg) during the measurement period. 

Guidance

In reference to the numerator element, only blood pressure readings performed by a clinician or a remote monitoring devise are acceptable for numerator compliance with this measure. 

Do not include BP readings: 

  • Taken during an acute inpatient stay or an ED visit

  • Taken on the same day as a diagnostic test or diagnostic or therapeutic procedure that requires a change in diet or change in medication on or one day before the day of the test or procedure, with the exception of fasting blood tests.

  • Reported or taken by the member

If no blood pressure is recorded during the measurement period, the patient's blood pressure is assumed "not controlled."

If there are multiple blood pressure readings on the same day, use the lowest systolic and  the lowest diastolic reading as the most recent blood pressure reading. 

 

ACO-40 (MH-1)

Depression Remission at 12 Months

Measure Description

The percentage of adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with major depression or dysthymia who reached remission 12 months (+/- 60 days) after an index event.

Denominator

Adolescent patients 12 to 17 years of age and adult patients 18 years of age or older with a diagnosis of major depression or dysthymia and an initial Patient Health Questionnaire-9 item version (PHQ-9) or Patient Health Questionnaire- Modified for Teens and Adolescents (PHQ-9M) score greater than nine during the index event. 

Numerator

Adolescent patients 12 to 17 years of age and adult patients 18 years of age and older who achieved remission at twelve months as demonstrated by a twelve month (+/- 60 days) PHQ-9 or PHQ-9M score of less than five.

Definition

Denominator Identification Period: The period in which eligible patients can have an index event. The denominator identification period occurs prior to the measurement period and is defined as 14 months to two months prior to the start of the measurement period. The denominator identification period is from 11/1/2019 to 10/31/2020. For patients with an index even, there needs to be enough time following the index for the patients to have the opportunity to reach remission twelve months +/- 60 days after the index event.

Index Event Date: The date in which the first instance of elevated PHQ-9 or PHQ-9M greater than nine AND diagnosis of depression or dysthymia occurs during the denominator identification period (11/01/2019 to 10/31/2020). Patients may be screened using PHQ-9 or PHQ-9M up to seven days prior to the encounter (including the day of the encounter).

Measure Assessment Period: The index event date marks the start of the measurement assessment period for each patient which is 14 months (12 months +/- 60 days). This 14 month measure assessment period allows for measurement of the patients remission status at both six and 12 months (Quality ID#441: Depression Remission at Six Months). This assessment period is fixed and does not "start over" with a higher PHQ-9 or PHQ-9M that may occur after the index event date.

Remission: Is defined as a PHQ-9 or PHQ-9M score of less than five.

Twelve Months: Is defined as the point in time from the index event date extending out twelve months and then allowing a grace period of sixty days prior to and sixty days after this date. The most recent PHQ-9 and PHQ-9M score less than five obtained during this four month period is deemed as remission at twelve months, values obtained prior to or after this period are not counted as numerator compliant (remission).

 

ACO-20 (PREV-5)

Breast Cancer Screening

Measure Description

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the measurement period. 

Denominator

Women 51-74 years of age with a visit during the measurement period.

Numerator

Women with one or more mammograms during the 27 months prior to the end of the measurement period. 

Definition

Mammography screening is defined by a bilateral screening (both breasts) of breast tissue. If only one breast is present, unilateral screening (one side) must be performed on the remaining breast.

Guidance

This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, or MRIs because they are not appropriate methods for primary breast cancer screening.

ACO-19 (PREV-6)

Colorectal Cancer Screening

Measure Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Denominator

Patients 50-75 years of age with a visit during the measurement period. 

Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

  • Fecal occult blood test (FBOT) during the measurement period

  • Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period.

  • Colonoscopy during the measurement period or the nine years prior to the measurement period

  • Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the the two years prior to the measurement period

  • Computed tomography (CT) Colonoscopy during the measurement period or the four years prior to the measurement period

Guidance

  • FOBT: It is up to the organization to determine whether the specific test or bran meets the definition

  • Do not count DRE, FOBT test performed in an office setting or performed on a sample collected via DRE.

  • Documentation in the medical record must include both of the following: A note indicating the date the colorectal cancer screening was performed AND the result or findings.

  • Documentation of 'normal' or 'abnormal' is acceptable

  • Patient Reported Requirement: Date (year) and type of test AND result/finding

  • Documentation of colorectal cancer screening may be completed during a telehealth encounter.

 
 

ACO-14 (PREV-7)

Influenza Immunization

Measure Description

Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

Denominator

All patients aged 6 months and older seen for a visit during the measurement period.

 

Numerator

Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization

 

Definition:

Previous Receipt: receipt of the current season's influenza immunization from another provider OR from the same provider prior to the visit to which the measure is applied (typically, prior vaccination would include influenza vaccine given since August 1st)

Guidance

  • FOBT: It is up to the organization to determine whether the specific test or bran meets the definition

  • Do not count DRE, FOBT test performed in an office setting or performed on a sample collected via DRE.

  • Documentation in the medical record must include both of the following: A note indicating the date the colorectal cancer screening was performed AND the result or findings.

  • Documentation of 'normal' or 'abnormal' is acceptable

  • Patient Reported Requirement: Date (year) and type of test AND result/finding

  • Documentation of colorectal cancer screening may be completed during a telehealth encounter.

ACO-17 (PREV-10)

Tobacco Use: Screening and Cessation Intervention

Measure Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Denominator

Patients 50-75 years of age with a visit during the measurement period. 

Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

  • Fecal occult blood test (FBOT) during the measurement period

  • Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period.

  • Colonoscopy during the measurement period or the nine years prior to the measurement period

  • Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the the two years prior to the measurement period

  • Computed tomography (CT) Colonoscopy during the measurement period or the four years prior to the measurement period

Guidance

  • FOBT: It is up to the organization to determine whether the specific test or bran meets the definition

  • Do not count DRE, FOBT test performed in an office setting or performed on a sample collected via DRE.

  • Documentation in the medical record must include both of the following: A note indicating the date the colorectal cancer screening was performed AND the result or findings.

  • Documentation of 'normal' or 'abnormal' is acceptable

  • Patient Reported Requirement: Date (year) and type of test AND result/finding

  • Documentation of colorectal cancer screening may be completed during a telehealth encounter.

ACO-18 (PREV-12)

Screening for Depression and Follow-up Plan

Measure Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Denominator

Patients 50-75 years of age with a visit during the measurement period. 

Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

  • Fecal occult blood test (FBOT) during the measurement period

  • Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period.

  • Colonoscopy during the measurement period or the nine years prior to the measurement period

  • Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the the two years prior to the measurement period

  • Computed tomography (CT) Colonoscopy during the measurement period or the four years prior to the measurement period

Guidance

  • FOBT: It is up to the organization to determine whether the specific test or bran meets the definition

  • Do not count DRE, FOBT test performed in an office setting or performed on a sample collected via DRE.

  • Documentation in the medical record must include both of the following: A note indicating the date the colorectal cancer screening was performed AND the result or findings.

  • Documentation of 'normal' or 'abnormal' is acceptable

  • Patient Reported Requirement: Date (year) and type of test AND result/finding

  • Documentation of colorectal cancer screening may be completed during a telehealth encounter.

ACO-42 (PREV-13)

Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

Measure Description

Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer

Denominator

Patients 50-75 years of age with a visit during the measurement period. 

Numerator

Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria:

  • Fecal occult blood test (FBOT) during the measurement period

  • Flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period.

  • Colonoscopy during the measurement period or the nine years prior to the measurement period

  • Fecal immunochemical DNA test (FIT-DNA) during the measurement period or the the two years prior to the measurement period

  • Computed tomography (CT) Colonoscopy during the measurement period or the four years prior to the measurement period

Guidance

  • FOBT: It is up to the organization to determine whether the specific test or bran meets the definition

  • Do not count DRE, FOBT test performed in an office setting or performed on a sample collected via DRE.

  • Documentation in the medical record must include both of the following: A note indicating the date the colorectal cancer screening was performed AND the result or findings.

  • Documentation of 'normal' or 'abnormal' is acceptable

  • Patient Reported Requirement: Date (year) and type of test AND result/finding

  • Documentation of colorectal cancer screening may be completed during a telehealth encounter.