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 ID NQF # Measure Type High Priority Measure? NQS Domain Data Submission Method(s)
181 0000 Process Yes Patient Safety Claims

Measure Description

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screen

Instructions

This measure is to be submitted a minimum of once during the performance period for patients seen during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding at the time of the qualifying visit. The documented follow up plan must be related to positive elder maltreatment screening, example: “Patient referred for protective services due to positive elder maltreatment screening.” Cognitively impaired patients are included in the denominator of this measure and need to be screened using an elder maltreatment screening tool.

NOTE: No notes for this Quality ID

Measure Submission

The listed denominator criteria is used to identify the intended patient population. The numerator quality-data codes included in this specification are used to submit the quality actions allowed by the measure. All measure-specific coding should be submitted on the claim(s) representing the eligible encounter.

Numerator

Patients with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of the encounter and follow-up plan documented on the date of the positive screen

Numerator Instructions:

Data not available

Numerator Quality-Data Coding Options

Elder Maltreatment Screen not Documented, Patient not Eligible

Denominator Exception: G8535:

Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter

OR

Elder Maltreatment Screen Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible for Follow-Up Plan

Denominator Exception: G8941:

Elder maltreatment screen documented as positive, followup plan not documented,documentation the patient is not eligible for follow-up plan at the time of the encounter

Elder Maltreatment Screen Documented as Positive AND Follow-Up Plan Documented

Performance Met: G8733:

Elder maltreatment screen documented as positive AND a follow-up plan is documented

OR

Elder Maltreatment Screen Documented as Negative, Follow-Up Plan not Required

Performance Met: G8734:

Elder maltreatment screen documented as negative, follow-up is not required

Elder Maltreatment Screen not Documented, Reason not Given

Performance Not Met: G8536:

No documentation of an elder maltreatment screen, reason not given

OR

Elder Maltreatment Screen Documented as Positive, Follow-Up Plan not Documented, Reason not Given

Performance Not Met: G8735:

Elder maltreatment screen documented as positive, followup plan not documented, reason not given

NUMERATOR NOTE:

Documentation of an elder maltreatment screening must include identification of the tool used. Examples of screening tools for elder maltreatment include, but are not limited to: Elder Abuse Suspicion Index (EASI), Vulnerability to Abuse Screening Scale (VASS) and Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). These tools are psychometrically sound instruments with demonstrated reliability and validity indices.

Denominator

All patients aged 65 years and older

Eligible cases are determined and must be reported, if either of the following conditions

Option 1 – Denominator Criteria (Eligible Cases):

Patients aged ≥ 65 years on date of encounter

AND

Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 90832, 90834, 90837, 96116, 96118, 96150, 96151, 96152, 97165, 97166, 97167, 97802, 97803, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0270, G0402, G0438, G0439, G0502, G0505

WITHOUT

Telehealth Modifier: GQ, GT, 95, POS 02

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