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CMS Measure ID:
Version:
7
NQF Number:
2872
Performance/Reporting Period
2019
Description:

Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the total score results for the standardized tools used for the assessment of cognition.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Assessment.
Inclusion Criteria: Includes only relevant concepts associated with total score results for the following standardized tools: -Blessed Orientation-Memory-Concentration Test (BOMC) -Montreal Cognitive Assessment (MoCA) -St. Louis University Mental Status Examination (SLUMS) -Mini-Mental State Examination (MMSE) [Note: The MMSE has not been well validated for non-Alzheimer's dementias] -Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) -Ascertain Dementia 8 (AD8) Questionnaire -Minimum Data Set (MDS) Brief Interview of Mental Status (BIMS) [Note: Validated for use with nursing home patients only] -Formal neuropsychological evaluation -Mini-Cog.
Exclusion Criteria: No exclusions.

Constrained to codes in the Assessment, Performed: Standardized Tools for Assessment of Cognition value set (2.16.840.1.113883.3.526.3.1006)

QDM Datatype and Definition (QDM Version 5.3)

Assessment, Performed

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The time the assessment is completed; Author dateTime.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent dementia diagnoses and mental degenerations diagnoses.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with dementia diagnoses and mental degeneration diagnoses.
Exclusion Criteria: Excludes dementia and mental degeneration diagnoses in remission.

Constrained to codes in the Diagnosis: Dementia & Mental Degenerations value set (2.16.840.1.113883.3.526.3.1005)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent visits for assessments for neuropsychological assessments.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with applicable neuropsychological assessments for behavioral health.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Behavioral/Neuropsych Assessment value set (2.16.840.1.113883.3.526.3.1023)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients living in assisted living, domiciliary care or rest homes who have had an interaction with a member of their medical team.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with services provided to new and established patients living in assisted living, domiciliary care or rest home. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes visits in settings other than assisted living, domiciliary care or rest homes.

Constrained to codes in the Encounter, Performed: Care Services in Long-Term Residential Facility value set (2.16.840.1.113883.3.464.1003.101.12.1014)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had a home health visit by a provider for the evaluation or management of a new or existing patient.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with home visits for the evaluation and management of a new or established patient. This is a grouping value set of CPT and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Home Healthcare Services value set (2.16.840.1.113883.3.464.1003.101.12.1016)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had an interaction with a member of their medical team on admission to a nursing facility.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with services provided to new and established patients in a nursing facility (skilled, intermediate and long-term care facilities).
Exclusion Criteria: Excludes visits in settings other than a nursing facility.

Constrained to codes in the Encounter, Performed: Nursing Facility Visit value set (2.16.840.1.113883.3.464.1003.101.12.1012)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent visits for evaluations for occupational therapy services.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with applicable codes for occupational therapy evaluations.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Occupational Therapy Evaluation value set (2.16.840.1.113883.3.526.3.1011)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had an office or other outpatient visit.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with comprehensive history, evaluation, and management of a patient in an office or outpatient facility. Patient can be presenting with problems that are minor to high severity. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes non-office visits, including telehealth services.

Constrained to codes in the Encounter, Performed: Office Visit 1 value set (2.16.840.1.113883.3.464.1003.101.12.1001)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had an outpatient interaction at an office with a member of their medical care team.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with comprehensive history, evaluation, and management of a patient in an office or outpatient facility. Patient can be presenting with problems that are minor to high severity. This is a grouping value set of CPT and SNOMED CT codes.
Exclusion Criteria: Excludes non-office visits, including telehealth services.

Constrained to codes in the Encounter, Performed: Outpatient Consultation value set (2.16.840.1.113883.3.464.1003.101.12.1008)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent provider interactions with patients that include both face-to-face and virtual types of encounters.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with provider interactions with patients that are conducted in an office or care setting, as well as interactions which may occur via virtual methods, such as telephone calls, emails, and letters.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Patient Provider Interaction value set (2.16.840.1.113883.3.526.3.1012)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent visits during which a psychiatric diagnostic evaluation is completed.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with visits with the completion of psychiatric diagnostic evaluations.
Exclusion Criteria: Excludes group psychotherapy or family psychotherapy.

Constrained to codes in the Encounter, Performed: Psych Visit - Diagnostic Evaluation value set (2.16.840.1.113883.3.526.3.1492)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent visits for psychotherapy.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with visits for individual psychotherapy services.
Exclusion Criteria: Excludes group psychotherapy or family psychotherapy.

Constrained to codes in the Encounter, Performed: Psych Visit - Psychotherapy value set (2.16.840.1.113883.3.526.3.1496)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent assessments performed for the evaluation of cognition.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Intervention.
Inclusion Criteria: Includes only relevant concepts associated with general concepts for assessments used to evaluate cognition.
Exclusion Criteria: Excludes standardized tools used to evaluate cognition.

Constrained to codes in the Intervention, Performed: Cognitive Assessment value set (2.16.840.1.113883.3.526.3.1332)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patient-specific reasons for when a patient does not receive a therapy or service.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Reason.
Inclusion Criteria: Includes only relevant concepts associated with patient-specific reasons for not receiving a therapy or service.
Exclusion Criteria: No exclusions.

Constrained to codes in the Negation Rationale: Patient Reason value set (2.16.840.1.113883.3.526.3.1008)

QDM Attribute and Definition (QDM Version 5.3)

Negation Rationale

The QDM attribute, negation rationale indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the 'negation rationale' attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies versus lack of documentation about allergies). QDM assumes that any information expected will be in a clinical record. The situation is different when something that normally would be expected to be done is specifically not done because of a valid clinical reason (such as the patient is allergic, they are suffering from a complication, or some other rationale. In this case, the 'thing not done' is rarely documented, especially as a code, in the patient record. To express such lack of evidence, an eCQM author should use a CQL 'not exists' expression noted in the examples, and they must also capture the Negation rationale to capture a reason for the absence, i.e., the reason must be included to qualify as a negation rationale type expression. The syntax in the human readable HQMF is described in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, 'Procedure, Performed not done.' QDM 5.5 uses the syntax, 'Procedure, not Performed' and this is then associated with either a DRC or a value set used to identify 'the expected thing,' that in this case was not done. Negation Rationale attribute value indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent whether the patient is Hispanic or not; ethnicity category defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Ethnicity.
Inclusion Criteria: Includes only relevant concepts associated with ethnicity defined as Hispanic or Latino, or Not Hispanic or Latino.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Ethnicity

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Payer.
Inclusion Criteria: Includes only relevant concepts associated with payer codes in the code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Payer

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the first day of insurance coverage with the referenced payer
  • stopTime – the last day of insurance coverage with the referenced payer

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the general race category reported by the patient - subject may have more than one; defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Race.
Inclusion Criteria: Includes only relevant concepts associated with the following race categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, White.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Race

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent gender identity restricted to only male and female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes relevant concepts associated with gender concepts for male and female only.
Exclusion Criteria: Excludes any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.