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Falls: Screening for Future Fall Risk

Specifications

General eCQM Information

CMS Measure ID CMS139v6
NQF Number 0101
Measure Description

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

Initial Population Patients aged 65 years and older with a visit during the measurement period
Denominator Statement

Equals Initial Population

Denominator Exclusions

Exclude patients who were in hospice care during the measurement year.

Exclude patients who were assessed to be non-ambulatory during the measurement period.

Numerator Statement

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

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward National Committee for Quality Assurance
Domain Patient Safety
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

A higher score indicates better quality

Guidance

None

Next Version
Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • ​Updated the exclusion statement in the header to exclude patients in hospice care from the Denominator. Measures that focus on screenings and procedures may not be appropriate or a priority for those who are at end of life (ie, on hospice).

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Modified the Denominator Exceptions to be Denominator Exclusions to simplify extraction for implementers.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • ​Removed documentation of medical reason for not conducting a falls screening from Denominator Exclusions because the 'Patient Not Ambulatory' value set covers this requirement.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Modified the Denominator Exceptions to be Denominator Exclusions to simplify extraction for implementers.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

Logic

  • Added new lines of logic to the Denominator Exclusions for all NCQA-stewarded measures (except CMS82) to ensure patients in hospice care are excluded from the Denominator.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Modified the Denominator Exceptions to be Denominator Exclusions to simplify extraction for implementers.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Removed lines of logic from Denominator Exclusions that referred to documentation of medical reason for not conducting falls screening. The ‘Patient Not Ambulatory’ criteria covers the measure requirement.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Replaced 'Risk Category Assessment' datatype with 'Assessment, Performed' datatype to conform with QDM 4.3 changes.

    Measure Section: Numerator

    Source of Change: QDM Standards

  • Modified the Denominator Exceptions to be Denominator Exclusions to simplify extraction for implementers.

    Measure Section: Denominator Exceptions

    Source of Change: Measure Lead

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 Encounter Inpatient (2.16.840.1.113883.3.666.5.307): Added Encounter Inpatient.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15): Added Hospice care ambulatory.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Health Care Facility for Hospice Care (2.16.840.1.113883.3.117.1.7.1.207): Added Discharged to Health Care Facility for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Home for Hospice Care (2.16.840.1.113883.3.117.1.7.1.209): Added Discharged to Home for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Medical Reason (2.16.840.1.113883.3.526.3.1007): Removed Medical Reason.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

Last Updated: May 06, 2020