Falls: Screening for Future Fall Risk

Last updated: May 3, 2018

CMS Measure ID: CMS139v6
Version: 6
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 Patient 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
Next Version:
Previous Version:
Improvement Notation:

A higher score indicates better quality

Guidance:

None

Specifications

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

External Resources