Falls: Screening for Future Fall Risk

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Measure Information	2023 Performance Period	2024 Performance Period	2025 Performance Period
Title	Falls: Screening for Future Fall Risk	Falls: Screening for Future Fall Risk	Falls: Screening for Future Fall Risk
CMS eCQM ID	CMS139v11	CMS139v12	CMS139v13
CBE ID*	Not Applicable	Not Applicable	Not Applicable
MIPS Quality ID	318	318	318
Measure Steward	National Committee for Quality Assurance	National Committee for Quality Assurance	National Committee for Quality Assurance
Description	Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period	Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period	Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
Measure Scoring	Proportion measure	Proportion measure	Proportion measure
Measure Type	Process	Process	Process
Stratification	*See CMS139v11.html	None	None
Risk Adjustment	*See CMS139v11.html	None	None
Rationale	*See CMS139v11.html	As the leading cause of both fatal and nonfatal injuries for older adults, falls are one of the most common and significant health issues facing people aged 65 years or older (Schneider, Shubert and Harmon, 2010). Moreover, the rate of falls increases with age (Dykes et al., 2010). Older... adults are five times more likely to be hospitalized for fall-related injuries than any other cause-related injury. It is estimated that one in every three adults over 65 will fall each year (Centers for Disease Control and Prevention, 2015). In those over age 80, the rate of falls increases to fifty percent (Doherty et al., 2009). Falls are also associated with substantial cost and resource use, approaching $30,000 per fall hospitalization (Woolcott et al., 2011). Identifying at-risk patients is the most important part of management, as applying preventive measures in this vulnerable population can have a profound effect on public health (al-Aama, 2011). Family physicians have a pivotal role in screening older patients for risk of falls, and applying preventive strategies for patients at risk (al-Aama, 2011). Show more > As the leading cause of both fatal and nonfatal injuries for older adults, falls are one of the most common and significant health issues facing people aged 65 years or older (Schneider, Shubert and Harmon, 2010). Moreover, the rate of falls increases with age (Dykes et al., 2010). Older adults are five times more likely to be hospitalized for fall-related injuries than any other cause-related injury. It is estimated that one in every three adults over 65 will fall each year (Centers for Disease Control and Prevention, 2015). In those over age 80, the rate of falls increases to fifty percent (Doherty et al., 2009). Falls are also associated with substantial cost and resource use, approaching $30,000 per fall hospitalization (Woolcott et al., 2011). Identifying at-risk patients is the most important part of management, as applying preventive measures in this vulnerable population can have a profound effect on public health (al-Aama, 2011). Family physicians have a pivotal role in screening older patients for risk of falls, and applying preventive strategies for patients at risk (al-Aama, 2011). Show less	As the leading cause of both fatal and nonfatal injuries for older adults, falls are one of the most common and significant health issues facing people aged 65 years or older (Schneider, Shubert, & Harmon, 2010). Moreover, the rate of falls increases with age (Dykes et al., 2010). Older... adults are five times more likely to be hospitalized for fall-related injuries than any other cause-related injury. It is estimated that one in every four adults over 65 will fall each year (Centers for Disease Control and Prevention, 2023). In those over age 80, the rate of falls increases to fifty percent (Doherty et al., 2009). Falls are also associated with substantial cost and resource use, approaching $30,000 per fall hospitalization (Woolcott et al., 2011). Identifying at-risk patients is the most important part of management, as applying preventive measures in this vulnerable population can have a profound effect on public health (al-Aama, 2011). Family physicians have a pivotal role in screening older patients for risk of falls, and applying preventive strategies for patients at risk (al-Aama, 2011). Show more > As the leading cause of both fatal and nonfatal injuries for older adults, falls are one of the most common and significant health issues facing people aged 65 years or older (Schneider, Shubert, & Harmon, 2010). Moreover, the rate of falls increases with age (Dykes et al., 2010). Older adults are five times more likely to be hospitalized for fall-related injuries than any other cause-related injury. It is estimated that one in every four adults over 65 will fall each year (Centers for Disease Control and Prevention, 2023). In those over age 80, the rate of falls increases to fifty percent (Doherty et al., 2009). Falls are also associated with substantial cost and resource use, approaching $30,000 per fall hospitalization (Woolcott et al., 2011). Identifying at-risk patients is the most important part of management, as applying preventive measures in this vulnerable population can have a profound effect on public health (al-Aama, 2011). Family physicians have a pivotal role in screening older patients for risk of falls, and applying preventive strategies for patients at risk (al-Aama, 2011). Show less
Clinical Recommendation Statement	*See CMS139v11.html	All older persons who are under the care of a heath professional (or their caregivers) should be asked at least once a year about falls. (American Geriatrics Society/British Geriatric Society/American Academy of Orthopaedic Surgeons, 2010) 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, 2010) Show more > All older persons who are under the care of a heath professional (or their caregivers) should be asked at least once a year about falls. (American Geriatrics Society/British Geriatric Society/American Academy of Orthopaedic Surgeons, 2010) 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, 2010) Show less	All older persons who are under the care of a heath professional (or their caregivers) should be asked at least once a year about falls. (American Geriatrics Society/British Geriatric Society/American Academy of Orthopaedic Surgeons (AGS/BGS/AAOS), 2010) 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, 2010) Show more > All older persons who are under the care of a heath professional (or their caregivers) should be asked at least once a year about falls. (American Geriatrics Society/British Geriatric Society/American Academy of Orthopaedic Surgeons (AGS/BGS/AAOS), 2010) 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, 2010) Show less
Improvement Notation	A higher score indicates better quality	A higher score indicates better quality	A higher score indicates better quality
Definition	*See CMS139v11.html	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. Show more > 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. Show less	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. Show more > 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. Show less
Guidance	This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	This eCQM is a patient-based measure. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.
Initial Population	Patients aged 65 years and older at the start of the measurement period with a visit during the measurement period	Patients aged 65 years and older at the start of the measurement period with a visit during the measurement period	Patients aged 65 years and older at the start of the measurement period with a visit during the measurement period
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Exclude patients who are in hospice care for any part of the measurement period	Exclude patients who are in hospice care for any part of the measurement period	Exclude patients who are in hospice care for any part of the measurement period
Numerator	Patients who were screened for future fall risk at least once within the measurement period	Patients who were screened for future fall risk at least once within the measurement period	Patients who were screened for future fall risk at least once within the measurement period
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS139v12	CMS139v13	No Version Available
Previous Version	No Version Available	CMS139v11	CMS139v12

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Specifications

Additional Resources for CMS139v12

CMS139v12-TRN.xlsx

Header

Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update

Logic

Added 'day of' specificity to hospice expressions for consistency.
Measure Section: Definitions
Source of Change: Measure Lead
Added QDM datatype 'Diagnosis' to the Hospice.'Has Hospice Services' definition referencing a new value set containing SNOMED finding codes to provide an additional approach for identifying patients receiving hospice care.
Measure Section: Definitions
Source of Change: Measure Lead
Updated the version number of the Hospice Library to v5.0.000.
Measure Section: Definitions
Source of Change: Annual Update
Updated the version number of the Hospice Library to v5.0.000.
Measure Section: Functions
Source of Change: Annual Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

Value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584): Deleted 3 SNOMED CT codes (170935008, 170936009, 305911006) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Added value set Hospice Diagnosis (2.16.840.1.113883.3.464.1003.1165) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Hospice Encounter (2.16.840.1.113883.3.464.1003.1003): Added 2 SNOMED CT codes (305911006, 385765002) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089): Added 4 CPT codes (98980, 98981, 99444, 99457) based on review by technical experts, SMEs, and/or public feedback. Added 3 HCPCS codes (G2250, G2251, G2252) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead