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Closing the Referral Loop: Receipt of Specialist Report

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Measure Information 2022 Performance Period 2023 Performance Period 2024 Performance Period 2025 Performance Period
Title Closing the Referral Loop: Receipt of Specialist Report Closing the Referral Loop: Receipt of Specialist Report Closing the Referral Loop: Receipt of Specialist Report Closing the Referral Loop: Receipt of Specialist Report
CMS eCQM ID CMS50v10 CMS50v11 CMS50v12 CMS50v13
CBE ID* Not Applicable Not Applicable Not Applicable Not Applicable
MIPS Quality ID 374 374 374 374
Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Description

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred

Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred

Percentage of patients with referrals, regardless of age, for which the referring clinician receives a report from the clinician to whom the patient was referred

Measure Scoring Proportion measure Proportion measure Proportion measure Proportion measure
Measure Type Process Process Process Process
Stratification *See CMS50v10.html *See CMS50v11.html

None

None

Risk Adjustment *See CMS50v10.html *See CMS50v11.html

None

None

Rationale *See CMS50v10.html *See CMS50v11.html

Problems in the outpatient referral and consultation process have been documented, including lack of timeliness of information and inadequate provision of information between the specialist and the requesting physician (Gandhi et al., 2000; Forrest et al., 2000; Stille et al., 2005). In a study of physician satisfaction with the outpatient referral process, Gandhi et al. (2000) found that 68% of specialists reported receiving no information from the primary care provider prior to referral visits, and 25% of primary care providers had still not received any information from specialists 4 weeks after referral visits. In another study of 963 referrals (Forrest et al., 2000), pediatricians scheduled appointments with specialists for only 39% and sent patient information to the specialists for only 51% of referrals.

In a 2006 report to Congress, the Medicare Payment Advisory Commission (MedPAC) found that care coordination programs improved quality of care for patients, reduced hospitalizations, and improved adherence to evidence-based care guidelines, especially among patients with diabetes and coronary heart disease. Associations with cost-savings were less clear; this was attributed to how well the intervention group was chosen and defined, as well as the intervention put in place. Additionally, cost-savings were usually calculated in the short-term, while some argue that the greatest cost-savings accrue over time (MedPAC, 2006).

Improved mechanisms for information exchange could facilitate communication between providers, whether for time-limited referrals or consultations, on-going co-management, or during care transitions. For example, a study by Branger, van’t Hooft, van der Wouden, Moorman & van Bemmel (1999) found that an electronic communication network that linked the computer-based patient records of physicians who had shared care of patients with diabetes significantly increased frequency of communications between physicians and availability of important clinical data. There was a 3-fold increase in the likelihood that the specialist provided written communication of results if the primary care physician scheduled appointments and sent patient information to the specialist (Forrest et al., 2000).

Care coordination is a focal point in the current health care reform and our nation's ambulatory health information technology framework. The National Priorities Partnership (2008) recently highlighted care coordination as one of the most critical areas for development of quality measurement and improvement.

Problems in the outpatient referral and consultation process have been documented, including inadequate care pathways between specialty and primary care. Studies suggest that both specialists and primary care providers (PCPs) are not satisfied with current processes (Institute for Healthcare Improvement / National Patient Safety Foundation, 2017; Greenwood-Lee et. al, 2018). Breakdowns in referral communication leads to worse health outcomes, increased cost, and appointment delays (Patel et. al, 2018; Odisho et. al, 2020). A 2018 analysis of primary care referrals to specialists found that of the 103,737 referral scheduling attempts analyzed, only 36,072 (34.8%) resulted in documented complete appointments, defined by the specialty clinician providing report to the PCP after the referral visit (Patel et. al, 2018).

Technological and process-based updates can improve the referral loop process and increase rates of closing the referral loop. Ramelson et. al (2018) enhanced an EHR's Referral Manager module to meet the Controlled Risk Insurance Company’s best practice steps and the requirements of both the CMS EHR Incentive Program and the National Committee for Quality Assurance Patient-Centered Medical Home program. Following the updates, 76.8% of referrals were completed and all defined referral process steps were easier to accomplish. Odisho et. al (2020) developed a referrals automation software to simplify the fax to referral process. Feedback from key stakeholder interviews noted that the software enhanced the referrals process by further streamlining and organizing the patient referral process. The Institute for Healthcare Improvement and the National Patient Safety Foundation (2017) reviewed the referrals process in the ambulatory care setting and found that organizational leaders, EHR vendors, regulatory agencies, clinicians, and patients all play a role in creating a referrals system that is effective, safe, convenient, and patient-centered.

Clinical Recommendation Statement *See CMS50v10.html *See CMS50v11.html

None

None

Improvement Notation

A higher score indicates better quality

A higher score indicates better quality

A higher score indicates better quality

A higher score indicates better quality

Definition *See CMS50v10.html *See CMS50v11.html

Referral: A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare & Medicaid Services.

Report: A written document prepared by the eligible clinician (and staff) to whom the patient was referred and that accounts for his or her findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, and is provided to the referring eligible clinician.

Referral: A request from one clinician to another clinician for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare & Medicaid Services.

Report: A written document prepared by the eligible clinician (and staff) to whom the patient was referred and that accounts for his or her findings, provides summary of care information about findings, diagnostics, assessments and/or plans of care, and is provided to the referring eligible clinician.

Guidance

The provider who refers the patient to another provider is the provider who should be held accountable for the performance of this measure.

The provider to whom the patient was referred should be the same provider that sends the report.

If there are multiple referrals for a patient during the measurement period, use the first referral.

The provider to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same provider who would report on the measure.

The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring provider which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible professionals or eligible clinicians reporting on this measure should note that all data for the reporting year is to be submitted by the deadline established by CMS. Therefore, eligible professionals or eligible clinicians who refer patients towards the end of the reporting period (i.e., November - December), should request that providers to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When providers to whom patients are referred communicate the consult report as soon as possible with the referring providers, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure.

Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time for the referring clinician to collect the consult report by the end of the measurement period.

If there are multiple referrals for a patient during the measurement period, use the first referral.

The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure.

The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the performance period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the performance period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS.

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.

The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure.

Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time for the referring clinician to collect the consult report by the end of the measurement period.

If there are multiple referrals for a patient during the measurement period, use the first referral.

The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure.

The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the performance period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the performance period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS.

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.

The clinician who refers the patient to another clinician is the clinician who should be held accountable for the performance of this measure.

Only the first referral made between January 1 – October 31 of the measurement period will be considered for this measure to allow adequate time for the referring clinician to collect the consult report by the end of the measurement period.

If there are multiple referrals for a patient during the measurement period, use the first referral.

The clinician to whom the patient was referred is responsible for sending the consultant report that will fulfill the communication. Note: this is not the same clinician who would report on the measure.

The consultant report that will successfully close the referral loop should be related to the first referral for a patient during the measurement period. If there are multiple consultant reports received by the referring clinician which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible clinicians reporting on this measure should note that all data for the measurement period is to be submitted by the deadline established by CMS. Therefore, eligible clinicians who refer patients towards the end of the measurement period (i.e., October), should request that clinicians to whom they referred their patients share their consult reports as soon as possible in order for those patients to be counted in the measure numerator during the measurement period. When clinicians to whom patients are referred communicate the consult report as soon as possible with the referring clinician, it ensures that the communication loop is closed in a timely manner and that the data are included in the submission to CMS.

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

Number of patients, regardless of age, who had a visit during the measurement period and were referred by one provider to another provider

Number of patients, regardless of age, who had an encounter during the measurement period and were referred by one clinician to another clinician on or before October 31

Number of patients, regardless of age, who had an encounter during the measurement period and were referred by one clinician to another clinician on or before October 31

Number of patients, regardless of age, who had an encounter during the measurement period and were referred by one clinician to another clinician on or before October 31

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions

None

None

None

None

Numerator

Number of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referred

Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred

Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred

Number of patients with a referral on or before October 31, for which the referring clinician received a report from the clinician to whom the patient was referred

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

None

None

None

None

Telehealth Eligible Yes Yes Yes Yes
Next Version No Version Available
Previous Version No Version Available
Specifications
Attachment Size
CMS50v13.html 64.3 KB
CMS50v13.zip 68.22 KB
CMS50v13-TRN.xlsx 23.42 KB
eCQM Jira Issue Tracker
*Note there may be more tickets in the eCQM Tracker - ONC Project Tracking System (Jira) for this measure. Only tickets tagged with their associated CMS measure ID appear.

Header

  • Updated the eCQM version number.

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    eCQM Version Number

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    Annual Update

  • Changed all references from NQF to CBE to identify the consensus-based entity role.

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    Annual Update

  • Updated copyright.

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  • Removed mention of 'performance period' in Guidance and replaced with 'measurement period' to align language with eCQMs where measurement period is defined as January 1, 20XX through December 31, 20XX.

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    Guidance

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    Annual Update

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

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  • Updated references and measure header to reflect current evidence and new or updated literature.

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Logic

  • Changed 'DateTime' to 'Date' for consistency across measures with the same specificity level with a comparison of day or Date.

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    Initial Population

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  • Added Psychology and Neuropsychology to Denominator eligible encounters to allow Psychology and Neuropsychology clinicians to be eligible to report the measure.

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  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

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  • Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.

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  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

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    Definitions

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  • Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'

    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.

  • Added value set Behavioral/Neuropsych Assessment (2.16.840.1.113883.3.526.3.1023) based on review by technical experts, SMEs, and/or public feedback.

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  • Value set Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001): Deleted 2 SNOMED CT codes (30346009, 37894004) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 CPT code (99201) based on review by technical experts, SMEs, and/or public feedback.

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  • Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.

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    Terminology

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    Annual Update

  • Added value set Psych Visit Diagnostic Evaluation (2.16.840.1.113883.3.526.3.1492) based on review by technical experts, SMEs, and/or public feedback.

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  • Added direct reference code CPT code (90839) based on review by technical experts, SMEs, and/or public feedback.

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  • Added direct reference code CPT code (96138) based on review by technical experts, SMEs, and/or public feedback.

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  • Added direct reference code CPT code (96136) based on review by technical experts, SMEs, and/or public feedback.

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  • Added direct reference code CPT code (96156) based on review by technical experts, SMEs, and/or public feedback.

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  • Added direct reference code CPT code (96112) based on review by technical experts, SMEs, and/or public feedback.

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Last Updated: Jun 03, 2024