No active measure groups appear for a patient - everything but MRF is grayed out.
When the Medical Record Found question is answered with anything other than Yes, then the patient is considered not qualified for the sample and all ranked measures will be disabled - you do not have to answer any further questions for that patient.
PREV-10 Tobacco Use -- What About E-Cigarettes?
In a GPRO Support call, CMS had the following question:
"In relation to the measures that diabetes – non-tobacco use and Prevention – screening for tobacco use, how are we to answer these questions in relation to electronic
The answer: "The measure owner does not consider e-cigarettes tobacco use."
So, for the purposes of reporting 2020, list e-cigarette users as Non-Tobacco Users.
Yes/No Questions Showing Blank
There are a number of questions in the Registry that have Yes/No as the answer options. In most cases, the prepopulated data will only show an answer when that answer is Yes. This is because we will only have evidence in the patient data to support a Yes answer; lack of data is not sufficient to confirm a No answer. This gives the practice an opportunity to review the patient data and select the appropriate answer.
For example, if a patient is ranked (required) for the Diabetes measure group the first question is: DM Confirmed? The answer options are:
- Not Confirmed - Diagnosis
- No - Other CMS Approved Reason
If the patient is found to qualify for the diabetes measures by having a diabetes diagnosis or a medication indicative of diabetes, then the answer will be set to Yes.
If no diagnosis or medication is found, then the answer will be left blank and the practice will need to determine the correct answer in this instance. Lack of evidence from the clinical data is not determined to be sufficient to select a No answer.
When there is evidence in the patient data that can support both a Yes and No answer, then the system will select the appropriate answer based on that evidence.
CMS Other Approved Reason
New for 2020 - requests to use CMS Other Approved Reason must be manually entered in the CMS Web Interface. Clinigence personnel will handle that task as long as you have selected this option as the answer and given details needed to support this request in the Comments for that specific measure.
Performance Report - Explaining the Met/Not Met counts for the Diabetes measures
This entry in the Performance Report is somewhat complicated because the DM-2 guideline is a Lower Is Better measure.
DM-2 - HbA1c Poor Control (>9) is a Lower Is Better measure so a patient who has an HbA1c <=9 will show in the Not Met column. This agrees with the Meets Target Criteria/Outside Target Criteria in the Performance Dashboard for this same measure.
CMS Web Interface FAQ
An FAQ from previous years’ CMS Support calls can be found here: qpp.cms.gov/about/resource-library