Index

• Sections
  • MIPS, MEDICAID & MEANINGFUL USE
  • HIGH PRIORITY MEASURES
  • NON-HIGH PRIORITY MEASURES
  • Adult Major Depressive Disorder (MDD): Suicide Risk Assessment
  • REPORTING
  • How to Use the Report

These are the 10 measures on which ICANotes can provide calculations. This course will cover those rules, how they are tracked within ICANotes, reporting, and exporting the report.

To enable CQM for your group, a Security Administrator needs to email ticket@icanotes.com.

MIPS, MEDICAID & MEANINGFUL USE

         Merit-Based Incentive Payment System (MIPS) 

         Medicaid / Meaningful Use

HIGH PRIORITY MEASURES

         Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

         Closing the Referral Loop: Receipt of Specialist Report

         Documentation of Current Medications in the Medical Record

         Use of High-Risk Medications in the Elderly

NON-HIGH PRIORITY MEASURES

Adult Major Depressive Disorder (MDD): Suicide Risk Assessment

         Dementia: Cognitive Assessment

         Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

         Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up

         Preventive Care and Screening: Screening for Depression and Follow-Up Plan

         Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

REPORTING

         Reporting

How to Use the Report

         Eligibility and Exception Information

Step 1 of 15

Medicaid / Meaningful Use

How long to report: 2020, the entire 365 days

How many to report on: Six measures need to be reported on. No patient sample or thresholds required.

Step 2 of 15

Merit-Based Incentive Payment System (MIPS) 

How long to report: 2020, the entire 365 days

How many to report on: Medicare providers need to report on six measures but one of the six must be a high priority. Report on all relevant measures including one high priority measure. Also, some are higher scoring in points so best to report on all to see over time which gets the highest percentage - numerator/denominator. The minimum patient sample for MIPS is 20 for each measure.

This replaces claims-based measures reporting or reporting via the registry. Not all measures you reported via claims or a registry can be reported via EHR, that is why you may see some that are different.

For MIPS the quality category is the highest scoring MIPS category - 45% of your total score.

There are 10 quality measures to choose from.

• Some are higher scoring in points so best to report on all to see over time which gets the highest  percentage - numerator/denominator.
• You must have a minimum of 20 patients in the  denominator for any measure to get as many points as possible. Data completeness for a quality measure is that 70 % of possible data for a measure has been submitted.
• If data completeness is not met on a measure, the measure will earn 1 point (small practices (15 clinicians or less) will earn 3 points for the measure).
• You can also earn up to 10 additional percentage points based on your improvement in the Quality performance category from the previous year.
• For ICANotes to collect Quality Measure data, service codes must be included in each note. 
• Check to make sure the clinician who is reporting on MIPS is the Principal clinician in a patient's chart face in Demographics to get credit for the Quality measure.  See below.

• Run your Quality measure reports once a month to see how you are doing. Go to Reports and click on Clinical Quality Measures. For details see Reporting in this document.

See below:

Step 3 of 15

Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

CMS#: CMS177v8

Measure Description: Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

High Priority 

Initial Patient Population: All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder

Denominator Statement: Equals Initial Population

Denominator Exclusions: None

Numerator Statement: Patient visits with an assessment for suicide risk

Numerator Exclusions: Not Applicable

Denominator Exceptions: None

Improvement Notation: Higher score indicates better quality

Guidance: A suicide risk assessment should be performed at every visit for major depressive disorder during the measurement period.

Suicide risk assessments completed via telehealth services can also meet numerator performance.

This measure is an episode-of-care