{"text_format":"3","workbook":"xlsx","n_sheets":6,"sheets":["Patient List","Yes or No DATA","Medical Reason Not Found DATA","Help","Change Log","Gender DATA"],"not_rendered":{"defined_names":3},"read":"whole","date_system":"1900"}

{"sheet":"Patient List","index":0,"n_rows":2,"n_cols":211,"rows_kept":2,"merged":[[0,2,0,12],[0,13,0,16],[0,17,0,21],[0,22,0,29],[0,30,0,37],[0,38,0,42],[0,43,0,54],[0,55,0,59],[0,60,0,64],[0,65,0,69],[0,70,0,74],[0,75,0,81],[0,82,0,88],[0,89,0,95],[0,96,0,105],[0,106,0,210]]}
[null,"Beneficiary Demographics","Beneficiary Demographics",{"$nulls":10},"Patient Confirmation",{"$nulls":3},"CARE-2: Screening for Future Fall Risk",{"$nulls":4},"DM: Diabetes Mellitus Composite",{"$nulls":7},"HTN-2: Controlling High Blood Pressure ",{"$nulls":7},"IVD-2: Ischemic Vascular Disease: Use of Aspirin or Another Antiplatelet",{"$nulls":4},"MH-1: Depression Remission at Twelve Months",{"$nulls":11},"PREV-5: Breast Cancer Screening",{"$nulls":4},"PREV-6: Colorectal Cancer Screening",{"$nulls":4},"PREV-7: Influenza Immunization",{"$nulls":4},"PREV-8: Pneumococcal Vaccination Status for Older Adults",{"$nulls":4},"PREV-9: Body Mass Index (BMI) Screening and Follow-Up Plan",{"$nulls":6},"PREV-10: Tobacco Use: Screening and Cessation Intervention",{"$nulls":6},"PREV-12: Screening for Depression and Follow-Up Plan",{"$nulls":6},"PREV-13: Statin Therapy for the Prevention and Treatment of Cardiovascular Disease",{"$nulls":9},"CARE-1: Medication Reconciliation Post-Discharge"]
["Errors","Beneficiary ID","Beneficiary ID Type","First Name","Last Name","Gender","Date of Birth (MM/DD/YYYY)","Medical Record Number","Clinic ID","Provider 1 NPI","Provider 2 NPI","Provider 3 NPI"," Comment","Can you locate the patient's medical record and is the patient qualified for the sample?","Disqualification Reason\nLearn More","Enter the date the patient became ineligible (MM/DD/YYYY)","Confirmation Comments","CARE-2 Rank","Is the patient qualified for this measure?\nLearn More","QPP Service Center Case Number  ","Was the patient screened for future fall risk at least once during the measurement period (January 1 - December 31, 2018)?\nLearn More","CARE-2 Comments (optional)","DM Rank","Does the patient have a documented history OR active diagnosis of diabetes during the measurement period and year prior to the measurement period (January 1, 2017 - December 31, 2018)?\nLearn More","QPP Service Center Case Number","Did the patient have one or more HbA1c tests performed during the measurement period (January 1 - December 31, 2018)?\nLearn More","Date drawn (MM/DD/YYYY)","HbA1c value (enter distinct value)","Did the patient have a retinal or dilated eye exam by an eye care professional during the measurement period (January 1 - December 31, 2018), OR a negative retinal exam (no evidence of retinopathy) by an eye care professional during 2017?\nLearn More","DM Comments (optional)","HTN-2 Rank","Does the patient have a documented diagnosis of essential hypertension within the first six months of 2018 or at any time prior to January 1, 2018 but does not end before January 1, 2018?\nLearn More","QPP Service Center Case Number   ","Was the patient's most recent blood pressure reading documented during the measurement period (January 1 - December 31, 2018)?\nLearn More","HTN-2 BP Date taken (MM/DD/YYYY)","HTN-2 BP Systolic                 (Enter Number)","HTN-2 BP Diastolic               (Enter Number)","HTN-2 Comments (optional)","IVD-2 Rank","Does the patient have a documented diagnosis of AMI, CABG or PCI between January 1 and December 31, 2017 OR an active diagnosis of IVD between January 1 and December 31, 2018?\nLearn More","QPP Service Center Case Number    ","Does the patient have documented use of aspirin or another antiplatelet during the measurement period (January 1 - December 31, 2018)?\nLearn More","IVD-2 Comments (optional)","MH-1 Rank","Does the patient have an active diagnosis of major depression or dysthymia between December 1, 2016 and November 30, 2017?\nLearn More","QPP Service Center Case Number     ","Did the patient have one or more PHQ-9s administered between December 1, 2016 and November 30, 2017?\nLearn More","Did the patient have a PHQ-9 score greater than 9 between December 1, 2016 and November 30, 2017?\nLearn More","PHQ-9 Index Date (MM/DD/YYYY)","PHQ-9 Score","Did the patient have one or more PHQ-9s administered during the measurement assessment period (12 months +/- 30 days from the index date)?","Did the patient achieve remission with a follow-up PHQ-9 performed and a score less than 5 at 12 months (+/- 30 days) of the initial Index Date?\nLearn More","PHQ-9 Follow-up Date (MM/DD/YYYY) \nLearn More","PHQ-9 Follow-up Score","MH-1 Comments (optional)","PREV-5 Rank","Is the patient qualified for this measure? \nLearn More","QPP Service Center Case Number      ","Was screening for breast cancer performed between October 1, 2016 and December 31, 2018?\nLearn More","PREV-5 Comments (optional)","PREV-6 Rank","Is the patient qualified for this measure?  \nLearn More","QPP Service Center Case Number       ","Is the patient's colorectal cancer screening current?\nLearn More","PREV-6 Comments (optional)","PREV-7 Rank","Is the patient qualified for this measure?   ","QPP Service Center Case Number        ","Did the patient receive an influenza immunization OR report previous receipt of an influenza immunization between August 1, 2017 and March 31, 2018?\nLearn More","PREV-7 Comments (optional)","PREV-8 Rank","Is the patient qualified for this measure?    ","QPP Service Center Case Number         ","Has the patient ever received a pneumococcal vaccination?\nLearn More","PREV-8 Comments (optional)","PREV-9 Rank","Is the patient qualified for this measure?\nLearn More ","QPP Service Center Case Number          ","Did the patient have a BMI documented during the most recent visit or in the last 12 months prior to the most recent visit?\nLearn More","Was the patient's BMI within normal parameters?\nLearn More","Was a follow-up plan documented?\nLearn More","PREV-9 Comments (optional)","PREV-10 Rank","Is the patient qualified for this measure?      ","QPP Service Center Case Number           ","Was the patient screened for tobacco use at least once during the measurement period and year prior to the measurement period (January 1, 2017 - December 31, 2018)?\nLearn More","Was the patient identified as a tobacco user during the most recent tobacco use screening?","Did the patient receive tobacco cessation intervention?\nLearn More","PREV-10 Comments (optional)","PREV-12 Rank","Is the patient qualified for this measure?       \nLearn More","QPP Service Center Case Number            ","Was the patient screened for depression using an age appropriate standardized tool during the measurement period (January 1 - December 31, 2018)?\nLearn More","Was the screen positive for depression during the measurement period (January 1 - December 31, 2018)?","Was a follow-up plan for depression documented during the measurement period (January 1 - December 31, 2018)?\nLearn More","PREV-12 Comments (optional)","PREV-13 Rank","Does the patient have a diagnosis of atherosclerotic cardiovascular disease (ASCVD)—active or history of—at any time up through December 31, 2018?\nLearn More","QPP Service Center Case Number             ","Has the patient ever had a fasting or direct laboratory test result of LDL-C≥190mg/dL OR were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia?\nLearn More","QPP Service Center Case Number              ","Is the patient aged 40-75 years of age and has a diagnosis of Type 1 or Type 2 diabetes?\nLearn More","Has the patient had an LDL-C of 70-189 mg/dL between January 1, 2016 and December 31, 2018?\nLearn More","QPP Service Center Case Number               ","Was the patient taking or prescribed statin therapy during the measurement period (January 1 - December 31, 2018)?\nLearn More","PREV-13 Comments (optional)","CARE-1 Rank","Is the patient qualified for this measure?          ","QPP Service Center Case Number                ","Number of Discharges","Discharge Date 1 (MM/DD/YYYY)","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?\nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?\nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?\nLearn More","CARE-1 Comments (optional)","Discharge Date 2 (MM/DD/YYYY)  ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days? \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge? \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?  \nLearn More","Discharge Date 3 (MM/DD/YYYY)       ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?   \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?  \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?   \nLearn More","Discharge Date 4 (MM/DD/YYYY)   ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?    \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?   \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?    \nLearn More","Discharge Date 5 (MM/DD/YYYY)    ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?     \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?    \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge? \nLearn More","Discharge Date 6 (MM/DD/YYYY)             ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?      \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?     \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?       \nLearn More","Discharge Date 7 (MM/DD/YYYY)              ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?  \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?      \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?        \nLearn More","Discharge Date 8 (MM/DD/YYYY)      ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?        \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?       \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?      \nLearn More","Discharge Date 9 (MM/DD/YYYY)           ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?\nLearn More ","Was the patient seen within 30 days following this inpatient facility discharge?        \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?          \nLearn More","Discharge Date 10 (MM/DD/YYYY)                  ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?          \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?         \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?           \nLearn More","Discharge Date 11 (MM/DD/YYYY)                   ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?           \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?          \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?            \nLearn More","Discharge Date 12 (MM/DD/YYYY)                    ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days? \nLearn More ","Was the patient seen within 30 days following this inpatient facility discharge?           \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?             \nLearn More","Discharge Date 13 (MM/DD/YYYY)                     ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?             \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?            \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?              \nLearn More","Discharge Date 14 (MM/DD/YYYY)                      ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?              \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?             \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?               \nLearn More","Discharge Date 15 (MM/DD/YYYY)                       ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?               \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?              \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                \nLearn More","Discharge Date 16 (MM/DD/YYYY)                        ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                 \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?               \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                 \nLearn More","Discharge Date 17 (MM/DD/YYYY)                           ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                   \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                 \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                   \nLearn More","Discharge Date 18 (MM/DD/YYYY)                          ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                  \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                  \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                    \nLearn More","Discharge Date 19 (MM/DD/YYYY)                            ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                    \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                    \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                     \nLearn More","Discharge Date 20 (MM/DD/YYYY)                             ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                     \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                      \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                       \nLearn More","Discharge Date 21 (MM/DD/YYYY)                                ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                        \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                        \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                         \nLearn More","Discharge Date 22 (MM/DD/YYYY)                                     ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                             \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                               \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                                 \nLearn More","Discharge Date 23 (MM/DD/YYYY)                                       ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                               \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                                   \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                           \nLearn More","Discharge Date 24 (MM/DD/YYYY)                                        ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                                \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                                    \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?                                       \nLearn More","Discharge Date 25 (MM/DD/YYYY)                                         ","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?                                   \nLearn More","Was the patient seen within 30 days following this inpatient facility discharge?                                     \nLearn More","Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?       \nLearn More "]

{"sheet":"Yes or No DATA","index":1,"n_rows":28,"n_cols":8,"rows_kept":28,"hidden":true,"merged":[[14,0,14,3]]}
["Yes","Yes","Yes","Yes","Yes","Yes","Medical Reasons","Patient is over 65 and weight reduction/gain would complicate other underlying health conditions"]
["No - Medical Record Not Found","No","No","Not Confirmed - Diagnosis","Denominator Exclusion","No - Other CMS Approved Reason","Patient Reasons","Patient in urgent or emergent medical situation"]
["Not Qualified for Sample","Not Screened for Medical Reasons","No - Other CMS Approved Reason","Denominator Exclusion","No - Other CMS Approved Reason","N/A","System Reasons","N/A"]
["N/A","N/A","N/A","No - Other CMS Approved Reason","N/A",null,"N/A"]
[{"$nulls":3},"N/A",{"$nulls":3},"Yes"]
["No","Yes","Yes",{"$nulls":4},"Not Confirmed - Diagnosis"]
["Yes","No","No - Other CMS Approved Reason","Yes","No","No",null,"No - Other CMS Approved Reason"]
["Not Screened / Unknown","No - Denominator Exception - Medical Reason","N/A","No - Diagnosis","Yes","No - Denominator Exception - Medical Reasons",null,"N/A"]
["No - Denominator Exception - Medical Reasons","N/A",null,"No - Other CMS Approved Reason","No - Denominator Exception - Medical Reasons","Yes"]
["N/A","No",null,"Denominator Exclusion","N/A","N/A",null,"Yes"]
[null,"Yes",null,"N/A",{"$nulls":3},"Not Confirmed - Diagnosis"]
[null,"N/A",{"$nulls":5},"Denominator Exclusion"]
[{"$nulls":4},"Yes","Yes",null,"No - Other CMS Approved Reason"]
[{"$nulls":4},"No","No - Diagnosis","Medical Reasons","N/A"]
["Table of Yes and No",{"$nulls":3},"No - Denominator Exclusion","N/A","Patient Reasons"]
["Y = Yes",{"$nulls":3},"No - Other CMS Approved Reason",null,"N/A","Yes"]
["N = No",{"$nulls":3},"N/A",null,null,"No"]
["N1 = Not Screened for Medical Reasons","No","No","No",{"$nulls":3},"No - Denominator Exception - Medical Reasons"]
["N2 = No - Other CMS Approved Reasons","Yes","Yes","Yes",{"$nulls":3},"N/A"]
["N3 = Denominator Exclusion","No - Denominator Exception - Medical Reasons","No - Denominator Exception - Medical Reasons","No - Denominator Exception - Medical Reasons"]
["N4 = Not Confirmed - Diagnosis","N/A","No - Denominator Exception - Patient Reasons","No - Denominator Exception - Patient Reasons",{"$nulls":3},"No"]
["N5 = No - Patient screens and is not a tobacco user",null,"No - Denominator Exception - System Reasons","N/A",{"$nulls":3},"Yes"]
["N6 = No - Denominator Exception","No","N/A",{"$nulls":4},"N/A"]
["N7 = Not Screened / Unknown","Yes",null,"Yes","Yes"]
["N8 = Denominator Exception - Medical Reasons","No - Denominator Exception - Medical Reasons",null,"No - Diagnosis","No"]
[null,"N/A",null,"No - Denominator Exclusion","No - Denominator Exclusion"]
[{"$nulls":3},"No - Other CMS Approved Reason","No - Other CMS Approved Reason"]
[{"$nulls":3},"N/A","N/A"]

{"sheet":"Medical Reason Not Found DATA","index":2,"n_rows":6,"n_cols":1,"rows_kept":6,"hidden":true}
[]
["In Hospice"]
["Moved out of Country"]
["Deceased"]
["Non-FFS Medicare"]
["N/A"]

{"sheet":"Help","index":3,"n_rows":40,"n_cols":4,"rows_kept":40,"merged":[[0,2,0,3],[1,2,1,3],[2,0,4,0],[2,2,2,3],[4,2,4,3],[5,0,6,0],[5,2,5,3],[6,2,6,3],[7,0,9,0],[7,2,7,3],[8,2,8,3],[9,2,9,3],[10,0,11,0],[10,2,10,3],[11,2,11,3],[12,0,13,0],[12,2,12,3],[13,2,13,3],[14,0,18,0],[14,2,14,3],[15,2,15,3],[16,2,16,3],[17,2,17,3],[18,2,18,3],[19,0,20,0],[19,2,19,3],[20,2,20,3],[21,0,22,0],[21,2,21,3],[22,2,22,3],[23,2,23,3],[24,2,24,3],[25,0,28,0],[25,2,25,3],[26,2,26,3],[27,2,27,3],[28,2,28,3],[29,0,30,0],[29,2,29,3],[30,2,30,3],[31,0,33,0],[31,2,31,3],[33,2,33,3],[34,0,38,0],[34,2,34,3],[35,2,35,3],[36,2,36,3],[37,2,37,3],[38,2,38,3],[39,0,39,3]]}
["Measure Name","Question","Help"]
["Patient Confirmation","Disqualification Reason","Select the disqualifying event that occurred during the measurement period (January 1 - December 31, 2018):\n• Patient entered hospice care (including non-hospice patients receiving palliative goals or comfort care).\n• Patient moved out of the country.\n• Patient died.\n• Non-FFS Medicare: Select this option if the patient was enrolled in Non-FFS Medicare at any time during the measurement period (i.e., commercial payers, Medicare Advantage, non-FFS Medicare, HMOs, etc.). This exclusion is intended to remove beneficiaries for whom fee-for-service Medicare is not the primary payer."]
["CARE-1","Was the patient discharged from an inpatient facility on the discharge date listed +/- 2 calendar days?","Synonyms for inpatient facility include: \n• Acute care hospital discharges, psychiatric inpatient discharges, skilled nursing facility discharges or rehabilitation inpatient discharges.\n• Inpatient discharges will be prepopulated from claims.\n• This measure is to be reported each time a patient was discharged from any inpatient facility and had an office visit within 30 days of discharge during the measurement period.\n• “Yes\" should be selected if the discharge date documented is within 2 calendar days before or 2 calendar days after the prefilled discharge date."]
[null,"Was the patient seen within 30 days following this inpatient facility discharge?","If there are no valid inpatient discharges/office visits within 30 days for this patient, the patient should be skipped and replaced."]
[null,"Were discharge medications reconciled with the current medication list in the outpatient medical record within 30 days following this inpatient facility discharge?","• The intent of the measure is to ensure that the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing ongoing care reviewed the discharge medications from the inpatient facility. If others perform the medication reconciliation, there must be documentation that the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing ongoing care is aware of the review.\n\n• Medication reconciliation post discharge may be completed during a telehealth encounter."]
["CARE-2","Is the patient qualified for this measure?","• Exclude patients who were assessed to be non-ambulatory during the measurement period.\n\n• Denominator Exclusion, count as non-ambulatory only if non-ambulatory at the most recent encounter during the measurement period.\n\n• Patient is not ambulatory, count as non-ambulatory only if non-ambulatory at the most recent encounter during the measurement period (i.e., patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair)."]
[null,"Was the patient screened for future fall risk at least once between January 1 and December 31, 2018?","Additional fall risk screening information:\n• A clinician with appropriate skills and experience may perform the screening\n\n• Setting of screening is not restricted to an office setting\n\n• Documentation of no falls is sufficient\n\n• Medical record must include documentation of screening performed\n\n• Any history of falls screening during the measurement period is acceptable as meeting the intent of the measure\n\n• A gait or balance assessment meets the intent of the measure\n\n• Screening for future fall risk may be completed during a telehealth encounter"]
["DM","Does the patient have a documented history OR active diagnosis of diabetes during the measurement period and year prior to the measurement period (January 1, 2017 - December 31, 2018)?","• Claims data cannot be used to confirm a diagnosis (DM, IVD, HTN, etc.,) used for sampling purposes as claims are the original source of the diagnosis sampling. Claims data can be used to prepare the CMS Web Interface Excel, but supporting medical record documentation will be required to substantiate what is reported in the event of an audit.\n\n• Active Diagnosis is defined as a diagnosis that is either on the patient’s problem list, a diagnosis code listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the measurement period."]
[null,"Did the patient have one or more HbA1c tests performed during the measurement period (January 1 - December 31, 2018)?","• Synonyms for HbA1c testing may include Glycohemoglobin A1c, HbA1c, Hemoglobin A1c, HgbA1c, A1c.\n\n• Use the following priority ranking: \n  ◦ Lab report draw date\n  ◦ Lab report date\n  ◦ Flow sheet documentation \n  ◦ Practitioner notes\n  ◦ Other documentation\n\n• Patient Reported Requirement: date and most recent value (distinct value required).\n\n• Ranges and thresholds do not meet criteria for this indicator. A distinct numeric result is required for\nnumerator compliance.\n\n• At a minimum, documentation in the medical record must include a note indicating the date on which the\nHbA1c test was performed and the result. If the day is unknown enter 01 i.e. 05/01/2018.\n\n• Documentation of most recent HbA1c result may be completed during a telehealth encounter.\n\n• HbA1c finger stick tests administered by a healthcare provider at the point of care are allowed."]
[null,"Did the patient have a retinal or dilated eye exam by an eye care professional during the measurement period (January 1 - December 31, 2018), OR a negative retinal exam (no evidence of retinopathy) by an eye care professional during 2017?","Additional retinal or dilated eye exam information:\n• If an endocrinologist or PCP performs the appropriate imaging in their office and the results are reviewed by an eye care professional (optometrist or ophthalmologist) during the measurement period or the year prior to the measurement period (if negative for retinopathy), then it is eligible for use in reporting. \n\n• If the eye exam is not performed or reviewed by an ophthalmologist or optometrist, results may be read by a qualified reading center that operates under the direction of a medical director who is a retinal specialist.\n\n• Use of retinal imaging is acceptable as long as it includes the date when the fundus photography was performed and evidence that an eye care professional reviewed the results.\n\n• Documentation of diabetic retinal disease screening may be completed during a telehealth encounter."]
["HTN-2","Does the patient have a documented diagnosis of essential hypertension within the first six months of 2018 or at any time prior to January 1, 2018 but does not end before January 1, 2018?","• Claims data cannot be used to confirm a diagnosis (DM, IVD, HTN, etc.,) used for sampling purposes as claims are the original source of the diagnosis sampling. Claims data can be used to prepare the CMS Web Interface Excel, but supporting medical record documentation will be required to substantiate what is reported in the event of an audit.\n\n• Denominator Exclusions:\n1) Patients with evidence of end stage renal disease (ESRD), dialysis or renal transplant before or during the measurement period are excluded. Also, exclude patients with a diagnosis of pregnancy during the measurement period.\nOR\n2) Patients age 65 and older in Institutional Special Needs Plans (SNP) or Residing in Long-Term Care with a POS code 32, 33, 34, 54 or 56 any time during the measurement period."]
[null,"Was the patient's most recent blood pressure reading documented during the measurement period (January 1 - December 31, 2018)?","• The blood pressure value cannot be completed during a telehealth encounter.\n\n• 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."]
["IVD-2","Does the patient have a documented diagnosis of acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period (January 1 - December 31, 2017) OR an active diagnosis of ischemic vascular disease (IVD) during the measurement period (January 1 - December 31, 2018)?","• Claims data cannot be used to confirm a diagnosis (DM, IVD, HTN, etc.,) used for sampling purposes as claims are the original source of the diagnosis sampling. Claims data can be used to prepare the CMS Web Interface Excel, but supporting medical record documentation will be required to substantiate what is reported in the event of an audit.\n\n• Active Diagnosis is defined as a diagnosis that is either on the patient’s problem list, a diagnosis code listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the denominator identification measurement period.\n\n• Denominator Exclusion, Patients who had documentation of use of anticoagulant medications overlapping between January 1, 2018 and December 31, 2018. \n\n• Denominator Exclusion medications include the following anticoagulant medications (i.e., Apixaban, Argatroban, Bilvalirudin, Dabigatran, Dalteparin, Desirudin, Edoxanban, Enoxaparin, Fondaparinus, Heparin, Lepirudin, Rivaroxaban, Tinzaparin, Warfarin)."]
[null,"Does the patient have documented use of aspirin or another antiplatelet during the measurement period (January 1 - December 31, 2018)?","• Oral Antiplatelet therapy includes: aspirin, clopidogrel or combination of aspirin and extended release dipyridamole, Prasugrel, Ticagrelor, Ticlopidine, and Yosprala.\n\n• Documented use of aspirin or another antiplatelet during the measurement period may be completed during a telehealth encounter."]
["MH-1","Does the patient have an active diagnosis of major depression or dysthymia between December 1, 2016 and November 30, 2017?","• Active Diagnosis is defined as a diagnosis that is either on the patient’s problem list, a diagnosis code listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the measurement period.\n\n• Claims data cannot be used to confirm a diagnosis (DM, IVD, HTN, etc.,) used for sampling purposes as claims are the original source of the diagnosis sampling. Claims data can be used to prepare the CMS Web Interface Excel, but supporting medical record documentation will be required to substantiate what is reported in the event of an audit.\n\n• Encounters in a Psychiatric, Behavioral, or Mental Health Setting require the diagnosis of depression or dysthymia to be a primary diagnosis.\n\n• Patient must be age 18 years or older at the time of the index event (confirming diagnosis and PHQ-9 greater than 9).\n\n• Denominator Exclusions, active diagnosis of bipolar disorder or personality disorder anytime prior to the end of the performance period. Patients who were a permanent nursing home resident any time during the denominator identification period or the measure assessment period.\n\n• Permanent Nursing Home Resident is defined as a patient who is residing in a long term residential facility any time during the denominator identification period or before the end of the measurement assessment period. It does not include patients who are receiving short term rehabilitative services following a hospital stay, nor does it include patients residing in assisted living or group home settings."]
[null,"Did the patient have one or more PHQ-9s administered between December 1, 2016 and November 30, 2017?","• If more than one PHQ-9 score was obtained between the 11 and 13 month window, select the most recent PHQ-9 date and score within that window.\n\n• PHQ-9 administration does not require a face-to-face visit; multiple modes of administration are acceptable (telephone, mail, e-visit, email, patient portal, iPad/tablet, or patient kiosk).\n\n• Index date marks the start of the measurement assessment period for each patient which is 13 months (12 months +/- 30 days) in length to allow for a follow-up PHQ-9 between 11 and 13 months following the index date. This assessment period is fixed and does not start over with a higher PHQ-9 that may occur after the index date."]
[null,"Did the patient have a PHQ-9 score greater than 9 between December 1, 2016 and November 30, 2017?","• Enter the first instance of PHQ-9 greater than 9 that is also associated with a diagnosis of major depression or dysthymia during the time period of December 1, 2016 and November 30, 2017. This is the Index Date for this patient and marks the start of the 13 month assessment period (12 months +/- 30 days).\n\n• All nine questions must be answered to have a valid summary score. If a patient chooses more than one response for a single question, select the “worse” response (higher number) to calculate the summary score."]
[null,"Did the patient achieve remission with a follow-up PHQ-9 performed and a score less than 5 at 12 months (+/- 30 days) of the initial Index Date?","• If more than one PHQ-9 score was obtained between the 11 and 13 month window, select the most recent PHQ-9 date and score within that window.\n\n• Scores obtained prior to or after this period are not counted as numerator compliant (remission).\n\n• Patient remission, a follow-up PHQ-9 result less than five may be determined during a telehealth encounter.\n\n• PHQ-9 administration does not require a face-to-face visit; multiple modes of administration are acceptable (telephone, mail, e-visit, email, patient portal, iPad/tablet, or patient kiosk)."]
[null,"Follow-up Date (MM/DD/YYYY)","• The index date marks the start of the measurement assessment period for each patient which is 13 months (12 months +/- 30 days) in length to allow for a follow-up PHQ-9 between 11 and 13 months following the index date. This assessment period is fixed and does not \"\"start over\"\" with a higher PHQ-9 that may occur after the index date.\n\n• In order to meet the measure, the PHQ-9 Follow-Up Date must be 12 months +/- 30 days of the Index PHQ-9 Test date."]
["PREV-5","Is the patient qualified for this measure? ","Denominator Exclusions:\n1) Women who had a bilateral mastectomy or who have a history of a bilateral mastectomy or for whom there is evidence of a right and a left unilateral mastectomy.\nOR\n2) Patients age 65 and older in Institutional Special Needs Plans (SNP) or Residing in Long-Term Care with a POS code 32, 33, 34, 54 or 56 any time during the measurement period."]
[null,"Was screening for breast cancer performed between October 1, 2016 and December 31, 2018?","• Total lookback period for a mammogram includes the measurement year, the year prior to the measurement year, and a 3 month grace period for a total of 27 months.\n\n• Documentation in the medical record must include both of the following: a note indicating the date the breast cancer screening was performed AND the result or findings.\n\n• Documentation of ‘normal’ or ‘abnormal’ is acceptable.\n\n• Patient Reported Requirement: date and type of test AND result/finding.\n\n• Screening includes: screening, diagnostic, film, digital or digital breast tomosynthesis (3D) mammography.\n\n• MRI, Ultrasound and Biopsies are not considered breast cancer screening for this measure.\n\n• Documentation of screening for breast cancer may be completed during a telehealth encounter."]
["PREV-6","Is the patient qualified for this measure?  ","Denominator Exclusions: \n1) Patients with a diagnosis or past history of total colectomy or colorectal cancer.\nOR\n2) Patients age 65 and older in Institutional Special Needs Plans (SNP) or residing in long-term care with a POS code 32, 33, 34, 54 or 56 any time during the measurement period."]
[null,"Is the patient's colorectal cancer screening current?","• Appropriate screenings are defined by any one or more of the following criteria below:\n  ◦ Fecal occult blood test (FOBT)* between January 1 and December 31, 2018\n  ◦ Flexible sigmoidoscopy between January 1, 2014 and December 31, 2018\n  ◦ Colonoscopy between January 1, 2009 and December 31, 2018\n  ◦ Computed tomography (CT) colonography between January 1, 2014 and December 31, 2018   \n  ◦ Fecal immunochemical DNA test (FIT-DNA) between January 1, 2016 and December 31, 2018\n\n• Do not count digital rectal exams (++DRE), FOBT tests performed in an office setting or performed on a sample collected via DRE.\n\n• 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.\n\n• Documentation of ‘normal’ or ‘abnormal’ is acceptable.\n\n• Patient Reported Requirement: Date (year) and type of test AND result/finding.\n\n• Documentation of colorectal cancer screening may be completed during a telehealth encounter."]
["PREV-7","Did the patient receive an influenza immunization OR report previous receipt of an influenza immunization between August 1, 2017 and March 31, 2018?","• If the CMS Web Interface has been prefilled with “Yes” based on claims data, no further action is required.\n\n• Documentation of patient reported previous receipt of influenza immunization is acceptable during the flu season.\n\n• Influenza immunization during the flu season or report of previous receipt may be completed during a telehealth encounter.\n\n• As a result of updated CDC/ACIP guidelines, which include the interim recommendation that live attenuated influenza vaccine (LAIV) should not be used due to low effectiveness against influenza A(H1N1)pdm09 in the United States during the 2013-14 and 2015-16 seasons, the measure specifications have been updated and no longer include LAIV or intranasal flu vaccine as an option for numerator eligibility.\n\n• Denominator Exceptions include:\n  ◦ Documentation of medical reason(s) for not receiving influenza immunization (eg, patient allergy, other medical reasons)\n  ◦ Documentation of patient reason(s) for not receiving influenza immunization (eg, patient declined, other patient reasons)   \n  ◦ Documentation of system reason(s) for not receiving influenza immunization (eg, vaccine not available, other system reasons)"]
["PREV-8","Has the patient ever received a pneumococcal vaccination?","• While the measure provides credit for adults 65 years of age and older who have ever received either the PCV13 or PPSV23 vaccine (or both) to adults 65 years of age and older, according to ACIP recommendations, patients should receive both vaccines. The order and timing of the vaccinations depends on certain patient characteristics, and are described in more detail in the ACIP recommendations.\n\n• PCV-7 is not a vaccine considered numerator compliant for this population.\n\n• Patient Reported Requirement: Date (year) and type of vaccine.\n\n• Pneumococcal vaccination status may be completed during a telehealth encounter."]
["PREV-9","Is the patient qualified for this measure?","• Exclude patients who met any of the following from this measure: \n  1) Pregnant\n  2) Refuse measurement of height and/or weight or refuse follow-up\n\n• The timing components for the Denominator Exclusions are as follows:\n  1) Patients who are pregnant any time during the measurement period\n  2) Patient refusal could occur at any encounter during the measurement period"]
[null,"Did the patient have a BMI documented during the most recent visit or in the last 12 months prior to the most recent visit?","• The 12-month look-back can be calculated as a look-back of less than 13 months from the most recent encounter.\n\n• The 12-month look-back could potentially fall outside the measurement year."]
[null,"Was the patient's BMI within normal parameters?","• Amputees are not considered denominator exceptions.\n\n• BMI calculation and recommended follow-up plan cannot be completed during a telehealth encounter."]
[null,"Was a follow-up plan documented?","• Amputees are not considered denominator exceptions.\n\n• BMI calculation and recommended follow-up plan cannot be completed during a telehealth encounter.\n\n• The timing component for the Denominator Exception is the date of the encounter with the calculated BMI or within the previous 12 months of the current encounter.\n\n• Denominator Exceptions include:\n   ◦ Elderly patients (65 or older) for whom weight reduction/weight gain would complicate other underlying health conditions such as the following examples:\n      ▪ Illness or physical disability\n      ▪ Mental illness, dementia, confusion\n      ▪ Nutritional deficiency, such as vitamin/mineral deficiency\n\n   ◦ Patients in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status."]
["PREV-10","Was the patient screened for tobacco use at least once during the measurement period and year prior to the measurement period (January 1, 2017 - December 31, 2018)?","• If there is more than 1 patient query regarding tobacco use, use the most recent during the 24 month period.\n\n• Within 24 months is defined as the 24-month look-back from the measurement period end date (1/1/2017 - 12/31/2018).\n\n• Screening for tobacco use may be completed during a telehealth encounter.\n\n• Denominator Exception:\nDocumentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason)."]
[null,"Did the patient receive tobacco cessation intervention?","• Screening for tobacco use and cessation intervention do not have to occur on the same encounter, but both must occur during the 24-month look-back period and the cessation intervention must occur after the most recent tobacco user status is documented.\n\n• Tobacco Cessation Intervention may be completed during a telehealth encounter.\n\n• Denominator Exception:\nDocumentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason)."]
["PREV-12","Is the patient qualified for this measure?       ","• Active Diagnosis is defined as a diagnosis that is either on the patient’s problem list, a diagnosis code listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the denominator identification measurement period.\n\n• Denominator Exception:\nPatients with an active diagnosis for depression or a diagnosis of bipolar disorder."]
[null,"Was the patient screened for depression using an age appropriate standardized tool during the measurement period (January 1 - December 31, 2018)?","Examples of depression screening tools include but are not limited to:\n\n• Adolescent Screening Tools (12-17 years)\n   ◦ Patient Health Questionnaire for Adolescents (PHQ-A)\n   ◦ Beck Depression Inventory-Primary Care Version (BDI-PC)\n   ◦ Mood Feeling Questionnaire (MFQ)\n   ◦ Center for Epidemiologic Studies Depression Scale (CES-D)\n   ◦ Patient Health Questionnaire (PHQ-9)\n   ◦ Pediatric Symptom Checklist (PSC-17)\n   ◦ PRIME MD-PHQ-2\n• Adult Screening Tools (18 years and older)\n   ◦ Patient Health Questionnaire (PHQ-9)\n   ◦ Beck Depression Inventory (BDI or BDI-II)\n   ◦ Center for Epidemiologic Studies Depression Scale (CES-D)\n   ◦ Depression Scale (DEPS)\n   ◦ Duke Anxiety-Depression Scale (DADS)\n   ◦ Geriatric Depression Scale (GDS)\n   ◦ Cornell Scale for Depression in Dementia (CSDD)\n   ◦ PRIME MD-PHQ-2\n   ◦ Hamilton Rating Scale for Depression (HAM-D)\n   ◦ Quick Inventory of Depressive Symptomatology Self-Report (QID-SR)\n• Use most recent screening for depression.","• Perinatal Screening Tools\n   ◦ Edinburgh Postnatal Depression Scale\n   ◦ Postpartum Depression Screening Scale\n   ◦ Patient Health Questionnaire 9 (PHQ-9)\n   ◦ Beck Depression Inventory\n   ◦ Beck Depression Inventory–II\n   ◦ Center for Epidemiologic Studies Depression Scale\n   ◦ Zung Self-rating Depression Scale\n• Although the patient may have access to the depression screening tool in advance of the appointment the depression screening results must be documented on the date of the encounter (date of appointment). The results must be reviewed/verified and documented by the eligible professional in the medical record on the date of the encounter to meet the screening portion of this measure.\n• Screening for depression may be completed during a telehealth encounter.\n• Denominator Exception timing is during the encounter during the measurement period.\n• Except patients from the denominator for medical reasons if:\nPatient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status.\nPatient's functional capacity OR motivation to improve may impact the accuracy of results of standardized depression assessment tools. For example: certain court appointed cases or cases of delirium.\n• Except patients from the denominator for patient reasons if:\nPatient refuses to participate."]
[null,"Was a follow-up plan for depression documented during the measurement period (January 1 - December 31, 2018)?","• Documentation of recommended follow-up plan for a positive depression screen may be completed during a telehealth encounter.\n\n• If recommended follow-up is additional screening, the additional screening must occur at the same encounter as the positive screen.\n\n• If additional screening is completed during the same encounter as the positive screen, the results of the additional screening is not necessary for data abstraction.\n\n• Positive or Negative-Whether or not a standardized screening tool score is considered positive or negative would be determined by the eligible professional administering and reviewing the standardized tool. If the result is positive, documentation of a recommended follow-up is required.\n\n• This measure does not require documentation of a specific score, just whether results of the normalized and validated depression screening tool used are considered positive or negative. Each standardized screening tool provides guidance on whether a particular score is considered positive for depression."]
["PREV-13","Does the patient have a diagnosis of atherosclerotic cardiovascular disease (ASCVD)—active or history of—at any time up through December 31, 2018?","\nClinical atherosclerotic cardiovascular disease (ASCVD) includes: • Acute coronary syndromes • History of myocardial infarction • Stable or unstable angina • Coronary or other arterial revascularization • Stroke or transient ischemic attack (TIA) • Peripheral arterial disease of atherosclerotic origin\n\nSelect \"No - Diagnosis\" if you are unable to confirm a diagnosis of ASCVD.\nDenominator exclusions include:\n• Active diagnosis of pregnancy\n• Breastfeeding\n• A diagnosis of rhabdomyolysis\n"]
[null,"Has the patient ever had a fasting or direct laboratory test result of LDL-C≥190mg/dL OR were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia?","Active Diagnosis is defined as a diagnosis that is either on the patient’s problem list, a diagnosis code listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the measurement period.\n\nSelect \"No - Diagnosis\" if any of the following are met:\n• Patient has never had a fasting or direct laboratory test result of LDL-C≥190mg/dL\n• Patient has never been previously diagnosed with or currently has an active diagnosis of familial or pure hypercholesterolemia\n• Laboratory unable to calculate LDL-C value due to high triglycerides\n• Test result is labeled \"unreliable\"\n\nDenominator exclusions include:\n• Active diagnosis of pregnancy\n• Breastfeeding\n• A diagnosis of rhabdomyolysis\n"]
[null,"Is the patient aged 40-75 years of age and has a diagnosis of Type 1 or Type 2 diabetes?","• Diabetes Diagnosis is defined as any history of diabetes, prior to or during the measurement period.\n\n• Select \"No - Diagnosis if the patient does not have a diagnosis of Type 1 or Type 2 diabetes."]
[null,"Has the patient had an LDL-C of 70-189 mg/dL between January 1, 2016 and December 31, 2018?","• Active Diagnosis is defined as a diagnosis that is either on the patient’s problem list, a diagnosis code listed on the encounter, or is documented in a progress note indicating that the patient is being treated or managed for the disease or condition during the measurement period.\n\n• Denominator exclusion should be active during the measurement period.\n\n• Denominator exclusions include: \n   ◦ Diagnosis of pregnancy \n   ◦ Breastfeeding \n   ◦ Diagnosis of rhabdomyolysis"]
[null,"Was the patient taking or prescribed statin therapy during the measurement period (January 1 - December 31, 2018)?","\nDocumentation of statin therapy prescribed or being taken during the measurement period cannot be completed during a telehealth encounter.\n\nExcept patients from the denominator with any of the following:\n• Adverse effect, allergy, or intolerance to statin medication\n• Receiving palliative care\n• Active liver disease or hepatic disease or insufficiency\n• End-stage renal disease (ESRD)\n• Diabetes - patients who have the most recent fasting or direct LDL-C laboratory test result < 70 mg/dL and are not taking statin therapy\n"]
["File Version: 1.0"]

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["CMS-Web-Interface-Excel-template.xlsx","V2","BA, DA","All Rows","Updated conditional formatting for MH-1 and PREV-13"]

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