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Measure Status: FINAL - PCPI Approved Physician Consortium for Performance Improvement®

The Physician Consortium for Performance Improvement®

Preventive Care & Screening Physician Performance Measurement Set

PCPI Approved

September 2008

FINAL –PCPI APPROVED Physician Consortium for Performance Improvement®

Work Group Members Preventive Care & Screening

Work Group Members Martin C. Mahoney, MD, PhD (Co-Chair) (family medicine) Stephen D. Persell, MD, MPH (Co-Chair) (internal medicine)

Gail M. Amundson, MD, FACP (internal medicine/geriatrics) G. Timothy Petito, OD, FAAO (optometry)

Joel V. Brill MD, AGAF, FASGE, FACG (gastroenterology) Rita F. Redberg, MD, MSc, FACC (cardiology)

Steven B. Clauser, PhD Barbara Resnick, PhD, CRNP (nurse practitioner)

Will Evans, DC, Phd, CHES (chiropractic) Sam JW Romeo, MD, MBA

Ellen Giarelli, EdD, RN, CRNP (nurse practitioner) Carol Saffold, MD (obstetrics & gynecology)

Amy L. Halverson, MD, FACS (colon & rectal surgery) Robert A. Schmidt, MD (radiology)

Alex Hathaway, MD, MPH, FACPM Samina Shahabbudin, MD (emergency medicine)

Charles M. Helms, MD, Phd (infectious disease) Melanie Shahriary RN, BSN (cardiology)

Kay Jewell, MD, ABHM (internal medicine/geriatrics) James K. Sheffield, MD (health plan representative)

Daniel Kivlahan, PhD (psychology) Arthur D. Snow, MD, CMD (family medicine/geriatrics)

Paul Knechtges, MD (radiology) Richard J. Snow, DO, MPH

George M. Lange, MD, FACP (internal medicine/geriatrics) Brooke Steele, MD

Trudy Mallinson, PhD, OTR/L/NZROT (occupational therapy) Brian Svazas, MD, MPH, FACOEM, FACPM (preventive medicine)

Elizabeth McFarland, MD (radiology) David J. Weber, MD, MPH (infectious disease)

Jacqueline W. Miller, MD, FACS (general surgery) Deanna R. Willis, MD, MBA, FAAFP (family medicine)

Adrienne Mims, MD, MPH (geriatric medicine) Charles M. Yarborough, III, MD, MPH (occupational medicine)

Sylvia Moore PhD, RD, FADA (dietetics)

Work Group Staff American Medical Association Kerri Fei, MSN, RN Kendra Hanley, MS Karen Kmetik, PhD Liana Lianov, MD, MPH Shannon Sims, MD, PhD Litjen Tan, MS, PhD Richard Yoast, PhD Consortium Consultants Rebecca Kresowik Timothy Kresowik, MD

© 2008 American Medical Association. All Rights Reserved. CPT® Copyright 2007 American Medical Association

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Table of Contents Purpose of Measures.......................................................................................................................................................... 4 Intended Audience and Patient Population................................................................................................................... 4 Importance of Topic: ......................................................................................................................................................... 4

Incidence, Prevalence, & Cost..................................................................................................................................... 4 Disparities ....................................................................................................................................................................... 5 Opportunity for Improvement/Gap or Variation in Care .................................................................................. 5 Available Evidence ........................................................................................................................................................ 6

Measure Harmonization.................................................................................................................................................... 6 Measure Testing & Implementation................................................................................................................................ 6 Measure Specifications ...................................................................................................................................................... 7 Measure Exclusions ............................................................................................................................................................ 7 Measure #1: Tobacco Use: Screening & Cessation Intervention.............................................................................10 Measure #2: Unhealthy Alcohol Use: Screening .........................................................................................................14 Measure #3: Unhealthy Alcohol Use: Screening & Brief Counseling.......................................................................17 Measure #7: Cervical Cancer Screening........................................................................................................................21 Measure #9: Pneumococcal Immunization..................................................................................................................25 Measure #10: Obesity Screening....................................................................................................................................28 Guideline Evidence Classification and Rating Schemes............................................................................................32 Physician Performance Measures (Measures) and related data specifications, developed by the Physician Consortium for Performance Improvement® (the Consortium), are intended to facilitate quality improvement activities by physicians. These Measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician who manages the care of a patient for a specific condition or for prevention. These performance Measures are not clinical guidelines and do not establish a standard of medical care. The Consortium has not tested its Measures for all potential applications. The Consortium encourages the testing and evaluation of its Measures. Measures are subject to review and may be revised or rescinded at any time by the Consortium. The Measures may not be altered without the prior written approval of the Consortium. Measures developed by the Consortium, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and American Medical Association, on behalf of the Consortium. Neither the Consortium nor its members shall be responsible for any use of these Measures. THE MEASURES ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND © 2008 American Medical Association. All Rights Reserved Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications. THE SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND. CPT® contained in the Measures specifications is copyright 2007 American Medical Association.


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Purpose of Measures These clinical performance measures, developed by the Physician Consortium for Performance Improvement® (PCPI), are designed for individual quality improvement. The measures may also be used in data registries, continuing medical education programs, and in board certification programs. Unless otherwise indicated, the measures are also appropriate for accountability if appropriate methodological, statistical, and implementation rules are achieved. The measure titles listed below may be used for accountability: Measure #1: Tobacco Use: Screening & Cessation Intervention Measure #2: Unhealthy Alcohol Use: Screening Measure #3: Unhealthy Alcohol Use: Screening & Brief Counseling Measure #7: Cervical Cancer Screening Measure #9: Pneumococcal Immunization Measure #10: Obesity Screening Measures that address influenza immunization, screening mammography, colorectal cancer screening, and lipid screening are forthcoming.

Intended Audience, Care Setting and Patient Population These measures are designed for use by physicians and eligible health professionals who provide preventive care and screening services to patients aged 18 years and older. These measures are meant to be used to calculate for performance and/or reporting at the individual physician level.

Importance of Topic Incidence, Prevalence, & Cost Tobacco Use

• In 2006, approximately 20.8% (45.3 million) U.S. adults were current smokers1. There has not been a significant change in this prevalence since 20042.

• During 1997-2001, approximately 438,000 premature deaths each year are attributed to smoking or exposure to second hand smoke3.

• The 2006 National Survey on Drug Use and Health (NSDUH) found that approximately 72.9 million (29.6%) Americans age 12 years and older were current users of tobacco4. A breakdown by type of tobacco is as follows:

o 61.6 million persons (25.0%) were current cigarette smokers o 13.7 million persons (5.6%) smoked cigars o 8.2 million persons (3.3%) use smokeless tobacco o 2.3 million (0.9%) smoked tobacco in a pipe

• Smoking attributable health care expenditures in 1998 were estimated to be $75.5 billion5. This, plus the estimated productivity losses of $92 billion from 1997-2001 combine for a total of over $167 billion per year3.

Alcohol Use

• The 2006 National Survey on Drug Use and Health reports that4: o Approximately half (50.9%; 125 million persons) of Americans age 12 years and older

reported being current drinkers of alcohol o 23% (57 million) persons age 12 years and older participated in binge drinking o Heavy drinking was reported by 6.9% (17 million) persons age 12 years and older

• In 2001, excessive alcohol use was responsible for 75,000 preventable deaths and 2.3 million years if potential life lost6.

• Economic costs associated with alcohol abuse are estimated to have been $184.6 billion in 1998. This represents a 25% increase over the previous estimate of $148 billion in 1992.


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Cervical Cancer • An estimated 11,070 women will be diagnosed with and 3,870 women will die from cervical

cancer in 20087Error! Bookmark not defined.. • The National Cancer Institute’s (NCI) Surveillance Epidemiology and End Results (SEER) Cancer

Statistics review reports that the age-adjusted incidence rate was 8.4 per 100,000 women per year based on new cases diagnosed in 2001-20058.

Pneumococcal Disease

• An estimated 40,000 cases and more than 4,400 deaths due to invasive pneumococcal disease occurred in 20059. More than half of these cases occurred in those who were candidates for pneumococcal immunization9.

• Incidence rates for invasive pneumococcal disease vary greatly by age group. In 1998, incidence rates were highest among children less than 2 years of age, followed by those 65 years of age and older9.

Obesity

• Since 1980, the number of persons considered to be overweight or obese has risen steadily10. • In 2003-2004 67% of adults aged 20-74 were overweight (includes the category of obese) and 34%

were obese. • The percent of adults considered overweight but not obese has remained about the same since

1960-1962 at about 32%-34%. Health Care Disparities The Partnership for Prevention/National Commission on Prevention Priorities published a report in August 2007 that outlines the disparities regarding use of preventive services. The data below is taken from this report11. Disparities were calculated using non-Hispanic whites as the reference group. The higher the value, the greater the disparity. For example, a value of .55 means that group was 55% less likely to receive the service than non-Hispanic whites. A value of zero means that there is no disparity, while a negative value means that racial/ethnic group was more likely to receive the service than non-Hispanic whites.

Preventive Service Hispanic Black only, non-Hispanic

Asian only, non-Hispanic

American Indian/Alaska

Native

Multiple Race, non-Hispanic

Smokers Advised to Quit adult smokers 18+

.48 .02 .40 .03 .03

Smokers Offered Assistance to Quit adult smokers 18+

.55 .00 N/A -.02 .11

Cervical Cancer Screening women 18-64

.11 .02 .25 N/A N/A

Pneumococcal Immunization adults 65+

.55 .34 .45 N/A N/A

As reported by the Partnership for Prevention/National Commission on Prevention Priorities, there is currently no data being collected across the national population regarding screening and brief intervention for unhealthy alcohol use12. Opportunity for Improvement / Gap or Variation in Care It has been reported that overall, adults receive approximately half of all recommended medical care.13,14 From 1998-200015:

• 3% of patients had smoking status documented at least once • 61% of patients that were documented smokers had their smoking status indicated on more than

50% of office visits • 12% of patients identified as smokers had documentation that advice to quit smoking was given

at least once during the year • 45% of patients were screened for problem drinking


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• 54.4% of women had the date and result of their last Pap smear documented in their medical record and 86.9% of women who had not had a Pap smear in the last three years had one performed

• 63.8% of patients aged 65 and older had documentation in their medical record of being offered the pneumococcal vaccine at least once

• 40.8% of patients’ medical records contained documentation of height and 66.4% of patients’ medical records contained documentation of weight at least once.

Additionally: • Data from the National Center for Health Statistics show that in 200516:

o 17.1% of adults aged 50-64 and 56.2% of adults aged 65 years and older reported ever receiving pneumococcal immunization.

Available Evidence Evidenced-based clinical practice guidelines and consensus standards are available for preventive care and screening services. This measurement set is based on clinical guidelines from the following:

• United States Preventive Services Task Force • Department of Health and Human Services/Public Health Service • National Quality Forum • Centers for Disease Control

The performance measures found in this document have been developed with these guidelines, enabling the physician to track his or her performance in individual patient care across patient populations. Please note that the provision of preventive care and screening services must be based on individual patient needs and professional judgment. Performance measures are not to be used as a substitute for clinical guidelines and individual physician clinical judgment. There may be instances where an individual patient falls outside the age range for the performance measure(s), however this does not mean that they should not receive the service. Whether or not a patient should undergo a specific screening service is a decision that needs to be made between the patient and the physician while weighing the risks and benefits of the service, along with individual patient preference.

Measure Harmonization: When hospital or plan-level measures are available for the same measurement topics, the PCPI attempts to harmonize the measures to the extent feasible. The measures in the Preventive Care & Screening measurement set were aligned with the National Committee for Quality Assurance’s Health Effectiveness Data Set (HEDIS), as well as other existing measures for preventive care and screening services. This may differ by measure. Please see individual measure documentation for specifics regarding harmonization.

Measure Testing & Implementation Measure Testing & Implementation Measures from the previous Preventive Care and Screening (2003) measurement set have been included in the following programs/demonstration projects. The PCPI welcomes additional feedback and information on the use and implementation of these measures.

• Centers for Medicare and Medicaid Services Physician Quality Reporting Initiative (PQRI)


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Measure Endorsement / Selection The following measures from the previous Preventive Care & Screening (2003) measurement set were endorsed by the NQF:

• Adult Influenza Immunization • Tobacco Use

The following measure from the previous Preventive Care and Screening (2003) measurement set was selected by the AQA:

• Tobacco Use

Measure Specifications: The PCPI seeks to specify measures for implementation using multiple data sources, including paper medical record, administrative (claims) data, and particular emphasis on Electronic Health Record Systems (EHRS). Draft specifications to report on these measures for Preventive Care and Screening using administrative (claims) data are included in this document. We have identified codes for these measures, including ICD-9 and CPT (Evaluation & Management Codes, Category I and where Category II codes would apply). Specifications for additional data sources, including EHRS, will be fully developed at a later date.

Measure Exclusions: For process measures, the Consortium provides three categories of reasons for which a patient may be excluded from the denominator of an individual measure:

• Medical reasons Includes:

- not indicated (absence of organ/limb, already received/performed, other) - contraindicated (patient allergic history, potential adverse drug interaction, other)

• Patient reasons

Includes: - patient declined - economic, social, or religious reasons - other patient reasons

• System reasons

Includes: - resources to perform the services not available - insurance coverage/payor-related limitations - other reasons attributable to health care delivery system

These measure exclusion categories are not available uniformly across all measures; for each measure, there must be a clear rationale to permit an exclusion for a medical, patient, or system reason. The exclusion of a patient may be reported by appending the appropriate modifier to the CPT Category II code designated for the measure:

• Medical reasons: modifier 1P • Patient reasons: modifier 2P • System reasons: modifier 3P

Although this methodology does not require the external reporting of more detailed exclusion data, the PCPI recommends that physicians document the specific reasons for exclusion in patients’ medical records for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic review and analysis of each physician’s exclusions data to identify practice patterns and opportunities for


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quality improvement. For example, it is possible for implementers to calculate the percentage of patients that physicians have identified as meeting the criteria for exclusion. Please refer to documentation for each individual measure for information on the acceptable exclusion categories and the codes and modifiers to be used for reporting. Measures #1-10 in the Preventive Care and Screening measurement set are process measures. For outcome measures, the PCPI specifically identifies all acceptable reasons for which a patient may be excluded from the denominator. Each specified reason is reportable with a CPT Category II code designated for that purpose. There are no outcome measures in the Preventive Care & Screening measurement set. The PCPI continues to evaluate and likely will evolve its methodology for handling exclusions as it gains experience in the use of the measures. The PCPI welcomes comments on its exclusions methodology

References 1 Centers for Disease Control and Prevention. Cigarette smoking among adults – United States. 2006. MMWR. 2007;56:1157-1161. 2 Centers for Disease Control and Prevention. Cigarette smoking among adults – United States, 2004. MMWR. 2005;54:1121-1124. 3 Centers for Disease Control and Prevention. Annual smoking-attributable mortality, years of potential life lost, and productivity losses – United States, 1997-2001. MMWR. 2005;54:625-628. 4 Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2006 National Survey on Drug Use and Health: National Findings. Rockville, MD. 2007. 5 Centers for Disease Control and Prevention. Smoking attributable mortality, morbidity, and economic costs (SAMMEC): adult and maternal child health software. Atlanta, GA. US Department of Health and Human Services, CDC; 2004. Cited by: Centers for Disease Control and Prevention. Annual smoking attributable mortality, years of potential life lost, and productivity losses – United States, 1997-2001. MMWR. 2005;54:625-628. 6 Centers for Disease Control and Prevention. Alcohol-attributable death and years of potential life lost – United States, 2001. MMWR. 2004;53:866-870. 7 American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society; 2008. 8 Ries LAG, Melbert D, Krapcho M, Stinchcomb DG, Howlader N, Horner MJ, Mariotto A, Miller BA, Feuer EJ, Altekruse SF, Lewis DR, Clegg, L, Eisner MP, Reichman M, Edwards BK (eds). SEER Cancer Statistics Review, 1975-2005, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/scr/1975_2005/, based on November 2007 SEER data submission, posted to the SEER website, 2008. 9 Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 10th ed. Washington DC: Public Health Foundation, 2007. 10 National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2007. Available at: http://www.cdc.gov/nchs/hus.htm. Accessed January 2008. 11 National Commission on Prevention Priorities. Preventive Care: A National Profile on Use, Disparities, and Health Benefits. Partnership for Prevention, August 2007. 12 National Commission on Prevention Priorities. Data Needed to Assess Use of High-Value Preventive Care: A Brief Report from the National Commission on Prevention Priorities. Partnership for Prevention, August 2007. 13 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N EnglJ Med. 2003;348:2635-2645. 14 Asch SM, Kerr EA, Keesey J, et al. Who is at greatest risk for receiving poor-quality health care? N Engl J Med. 2006;354:1147-1156. 15 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor quality health care? N Engl J Med 2006;354:1147-1156. Available at http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008.

http://seer.cancer.gov/scr/1975_2005/

http://www.cdc.gov/nchs/hus.htm

http://www.rand.org/pubs/working_papers/WR-174-1


16 National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2007. Available at: http://www.scs.gov/nchs/hus.htm. Accessed January 2008.


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http://www.scs.gov/nchs/hus.htm

Measure Status: FINAL - PCPI Approved Physician Consortium for Performance Improvement®

Measure #1: Tobacco Use: Screening & Cessation Intervention

Preventive Care & Screening

This measure may be used as an Accountability measure.

Measure Description Percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user

Measure Components

Numerator Statement

Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user *Includes use of any type of tobacco ** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy

Denominator Statement

All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two year measurement period

Denominator Exclusions

Documentation of medical reason(s) for not screening for tobacco use (eg, limited life expectancy)

Supporting Guideline

The following evidence statements are quoted verbatim from the referenced clinical guidelines. The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) (USPSTF, 2003)1 During new patient encounters and at least annually, patients in general and mental healthcare settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any tobacco use. (NQF, 2007)2 All patients should be asked if they use tobacco and should have their tobacco-use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco status or the use of other reminder systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A) (U.S. Department of Health & Human Services-Public Health Service, 2008)3 All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A) (U.S. Department of Health & Human Services-Public Health Service, 2008)3 Minimal interventions lasting less than 3 minutes increase overall tobacco abstinence rates. Every tobacco user should be offered at least a minimal intervention whether or not he or she is referred to an intensive intervention. (Strength of Evidence = A) (U.S. Department of Health & Human Services-Public Health Service, 2008)3


Measure Importance Relationship to desired outcome

There is good evidence that tobacco screening and brief cessation intervention (including counseling and pharmacotherapy) in the primary care setting is successful in helping tobacco users quit1. Tobacco users who are able to stop smoking lower their risk for heart disease, lung disease, and stroke1.

Opportunity for Improvement

From 1998-2000,

• 43% of patients had smoking status documented at least once4

• 61% of patients that were documented smokers had their smoking status indicated on more than 50% of office visits4

• 12% of patients identified as smokers had documentation that advice to quit smoking was given at least once during the year4

Exclusion Justification

The measure development Work Group determined that the provision of preventive care and screening services—such as patients with terminal illness—is not appropriate in all cases. Therefore, a medical exclusion is included in this measure so that those patients may be excluded from the denominator.

Harmonization with Existing Measures

This measure was harmonized to the extent feasible with the National Committee for Quality Assurance Health Effectiveness Data Information Set (HEDIS).

Measure Designation Measure Purpose • Quality Improvement

• Accountability

Type of Measure • Process

Care Setting • Ambulatory Care

Data Source • Administrative data • Medical record • Electronic health record system • Prospective data collection flowsheet

Technical Specifications: Administrative Data

Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. The specifications listed below are those needed for performance calculation. Additional CPT II codes may be required depending on how measures are implemented. (Reporting vs. Performance)

Denominator (Eligible Population)

All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two year measurement period CPT E/M Service code: Two visits during the two year measurement period

• 99201, 99202, 99203, 99204, 99205 (Office/other outpatient services-new patient)

• 99212, 99213, 99214,99215 (Office/other outpatient services-established patient)

• 97003, 97004 (Occupational therapy evaluations) • 90801, 90802 (Psychiatric diagnostic or evaluative interview) • 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813,

90814, 90815 (Psychiatric therapeutic procedures-office or other outpatient)• 90845, 90862, (Other Psychotherapy) • 96150, 96152 (Health and Behavior Assessment/Intervention)


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OR CPT E/M Service Code: One preventive care visit during the two year measurement period

• 99385, 99386, 99387 (Initial comprehensive preventive medicine-new patient)

• 99395, 99396, 99397 (Initial comprehensive preventive medicine-established patient)

• 99401, 99402, 99403, 99404 (Preventive medicine, Individual Counseling) • 99411, 99412 (Preventive medicine, Group Counseling) • 99420 (Other preventive medicine services-administration and

interpretation of health risk assmt) • 99429 (Unlisted preventive)

Numerator Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user *Includes use of any type of tobacco ** Cessation counseling intervention includes brief counseling (3 minutes or less), and/or pharmacotherapy CPT Category II code (in development):

• 4XXXF: Patient screened for tobacco use AND received tobacco cessation counseling, if identified as a tobacco user

OR CPT Category I code-Smoking and tobacco-use cessation counseling *The following codes are applicable if the patient screened positive for smoking/tobacco use and counseling was provided..

• 99406: Smoking/tobacco counseling 3-10 minutes • 99407: Smoking/tobacco counseling greater than 10 minutes


Documentation of medical reason(s) for screening for tobacco use (eg, limited life expectancy)

• Append modifier to CPT Category II code: 4XXXF-1P

Technical Specifications: Electronic Health Record System Technical specifications for electronic health record systems are developed for all measures after they are approved.

Technical Specifications: Prospective Data Collection Flowsheet Prospective data collection flowsheets are developed for measure sets after they are approved.

References 1 U. S. Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-related diseases: Recommendation statement. November 2003. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic/3rduspstf/tobaccounrs/htm. Accessed November 2007.

http://www.ahrq.gov/clinic/3rduspstf/tobaccounrs/htm


2 National Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence-based treatment practices. Washington, DC: National Quality Forum; 2007. 3 Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008. 4 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor quality health care? N Engl J Med 2006;354:1147-1156. Available at http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008.


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Measure #2: Unhealthy Alcohol Use: Screening Preventive Care & Screening


Measure Description Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method

Measure Components

Numerator Statement

Patients who were screened for unhealthy alcohol use* at least once during the two-year measurement period using a systematic screening method† *Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. Risky use is defined as >7 standard drinks per week or >3 drinks per occasion for women and persons >65 years of age; >14 standard drinks per week or >4 drinks per occasion for men ≤65 years of age.


All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two-year measurement period


Documentation of medical reason(s) for not screening for unhealthy alcohol use (eg, limited life expectancy)


The following evidence statements are quoted verbatim from the referenced clinical guidelines. The USPSTF strongly recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. (B Recommendation) (USPSTF, 2004)1 During new patient encounters and at least annually, patients in general and mental healthcare settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any tobacco use. (NQF, 2007)2 All patients identified with alcohol use in excess of National Institute on Alcohol Abuse and Alcoholism guidelines and/or any tobacco use should receive brief motivational counseling intervention by a healthcare worker trained in this technique. (NQF, 20072)


Screening for unhealthy alcohol use can identify patients can identify patients whose habits may put them at risk for adverse health outcomes due to their alcohol use. While this measure does not require counseling for those patients to be found at risk, brief counseling interventions for unhealthy alcohol use have shown to be effective in reducing alcohol use.3,4 ,5 It would be expected that if a provider found their patient to be at risk after screening that intervention would be provided.

† A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to the National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who Drink Too Much: A Clinician’s Guide for additional information regarding systematic screening methods., Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf.


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From 1998-2000, 45% of patients were screened for problem drinking6.


The measure development Work Group determined that the provision of preventive care and screening services—such as for patients with terminal illness—is not appropriate in all cases. Therefore, a medical exclusion is included in this measure so that those patients may be excluded from the denominator.




• Accountability







All patients aged 18 years and older who were seen at least twice for any visits or who had at least one preventive care visit during the two-year measurement period CPT E/M Service code: Two visits during the two year measurement period

• 99201, 99202, 99203, 99204, 99205 (Office or other outpatient services – new patient)

• 99212, 99213, 99214, 99215 (Office or other outpatient services – established patient)

• 90801, 90802 (Psychiatric diagnostic or evaluative interview) • 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813,

90814, 90815 (Psychiatric therapeutic procedures – office or other outpatient)

• 90845, 90862 (Other psychotherapy) • 96150, 96152 (Health and Behavior Assessment/Intervention) • 97003, 97004 (Occupational therapy evaluations) • 97802, 97803, 97804, G0270, G0271 (Medical Nutrition Therapy) • 98960, 98961, 98962 (Education and Training – patient self-management)


• 99385, 99386,99387 (Initial comprehensive preventive medicine – new patient)


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• 99395, 99396, 99397 (Initial comprehensive preventive medicine – established patient)

• 99401,99402, 99403, 99404 (Preventive medicine – Individual Counseling) • 99411, 99412 (Preventive medicine – Group counseling) • 99420 (Other preventive medicine services – administration • 99429 (Unlisted preventive)

Numerator Patients who were screened for unhealthy alcohol use* at least once during the two-year measurement period using a systematic screening method‡ CPT Category II code (in development):

• 3016F: Patient screened for unhealthy alcohol use using a systematic screening method



• Append modifier to CPT Category II code: 3016F-1P



References 1U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. April 2004. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic.3rd uspstf/alcohol/alcomisrs.htm. Accessed November 2007. 2 National Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence-based treatment practices. Washington, DC: National Quality Forum; 2007. 3 Fleming MF. Screening and brief intervention in primary care settings. Alcohol Res Health 2005/2005;28:57-62 4Saitz R. Unhealthy alcohol use. N Engl J Med 2005;352:596-607. 5 Kaner EFS, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub3. 6 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor quality health care? N Engl J Med 2006;354:1147-1156. Available at http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008. ‡ A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to the National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who Drink Too Much: A Clinician’s Guide for additional information regarding systematic screening methods., Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf.


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http://www.ahrq.gov/clinic.3rd%20uspstf/alcohol/alcomisrs.htm




Measure #3: Unhealthy Alcohol Use: Screening & Brief Counseling

Preventive Care & Screening


Measure Description Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use at least once during the two-year measurement period using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user

Measure Components

Numerator Statement

Patients who were screened for unhealthy alcohol use* at least once during the two-year measurement period using a systematic screening method§ AND who received brief counseling** if identified as an unhealthy alcohol user *Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence. Risky use is defined as >7 standard drinks per week or >3 drinks per occasion for women and persons >65 years of age; >14 standard drinks per week or >4 drinks per occasion for men ≤65 years of age. **Brief counseling (5-15 minutes) may include: feedback on alcohol use and harms; identification of high risk situations for drinking and coping strategies; increased motivation and the development of a personal plan to reduce drinking5.


All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two-year measurement period




The following evidence statements are quoted verbatim from the referenced clinical guidelines. The USPSTF strongly recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. (B Recommendation) (USPSTF, 20041) During new patient encounters and at least annually, patients in general and mental healthcare settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any tobacco use. (NQF, 20072) All patients identified with alcohol use in excess of National Institute on Alcohol Abuse and Alcoholism guidelines and/or any tobacco use should receive brief motivational counseling intervention by a healthcare worker trained in this technique. (NQF, 20072)

§ A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to the National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who Drink Too Much: A Clinician’s Guide for additional information regarding systematic screening methods., Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf.


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Brief counseling interventions for unhealthy alcohol use have shown to be effective in reducing alcohol use3,4,5.


From 1998-2000, 45% of patients were screened for problem drinking6.


The measure development Work Group determined that the provision of preventive care and screening services—such as for patients with terminal illness—is not appropriate in all cases. Therefore, a medical exclusion is included in this measure so that those patients may be excluded from the denominator.




• Accountability



Data Source • Administrative Data combined with medical record review • Medical record • Electronic health record system • Prospective data collection flowsheet


Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria. The specifications listed below are those needed for performance calculation.



• 99201, 99202, 99203, 99204, 99205 (Office or other outpatient services-new patient)

• 99212, 99213, 99214, 99215 (Office or other outpatient services- established patient)

• 90801, 90802 (Psychiatric diagnostic or evaluative interview) • 90804, 90805, 90806, 90807, 90808, 90809, 90810, 90811, 90812, 90813,

90814, 90815 (Psychiatric therapeutic procedures-office or other outpatient)• 90845, 90862 (Other Psychotherapy) • 96150, 96152 (Health and Behavior Assmt/Intervention) • 97003, 97004 (Occupational therapy evaluations) • 97802, 97803, 97804, G0270, G0271 (Medical Nutrition Therapy) • 98960, 98961, 98962 (Education and Training-patient self-management)

OR


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19

CPT E/M Service Code: One preventive care visit during the two year measurement period





Numerator Patients who were screened for unhealthy alcohol use* at least once during the two-year measurement period using a systematic screening method** AND who received brief counseling if identified as an unhealthy alcohol user The numerator for this measure cannot be captured by a CPT Category II code. Data may be collected from other sources, such as medical record abstraction, prospective data collection flowsheet, or through electronic health record systems. Additionally, the numerator can be met through identification of the CPT Category I code listed below. Please note that the CPT Category I Codes below require at least a fifteen minute intervention, but the numerator of this performance measure does not have a length of time requirement. Shorter interventions also meet the numerator requirements. CPT Category I code-Screening and Brief Intervention *The following codes are applicable if the patient screened positive for unhealthy alcohol use and brief interventional services were provided for at least 15 minutes. Services of less than 15 minutes may not be reported using the following codes.

• 99408, 99409 (Alcohol structured screening and brief intervention)


Documentation of medical reason(s) for screening for unhealthy alcohol use (eg, limited life expectancy)



References ** A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to the National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who Drink Too Much: A Clinician’s Guide for additional information regarding systematic screening methods., Available at: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf.


1 U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. April 2004. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic.3rd uspstf/alcohol/alcomisrs.htm. Accessed November 2007. 2 National Quality Forum. National voluntary consensus standards for the treatment of substance use conditions: evidence-based treatment practices. Washington, DC: National Quality Forum; 2007. 3 Fleming MF. Screening and brief intervention in primary care settings. Alcohol Res Health 2005/2005;28:57-62 4 Saitz R. Unhealthy alcohol use. N Engl J Med 2005;352:596-607. 5 Kaner EFS, Beyer F, Dickinson HO, Pienaar E, Campbell F, Schlesinger C, Heather N, Saunders J, Burnand B. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004148. DOI: 10.1002/14651858.CD004148.pub3. 6 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor quality health care? N Engl J Med 2006;354:1147-1156. Available at http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008.


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Measure #7: Cervical Cancer Screening Preventive Care & Screening


Measure Description Percentage of female patients aged 21 through 65 years who have documentation of the performance of current cervical cancer screening with results during the two-year measurement period

Measure Components

Numerator Statement

Patients with documentation of the performance of current* cervical cancer screening with results *Current cervical cancer screening is defined as having cervical cytology testing performed at least once within the last three years.


All female patients aged 21 through 65 years who were seen at least twice for any visits or who had at least one preventive care visit during the two-year measurement period


Documentation of medical reason(s) for not having cervical cancer screening performed at least once in the last three years (eg, limited life expectancy, patient has a history of complete cervix removal) Documentation of patient reason(s) for not having cervical cancer screening performed at least once in the last three years (eg, patient declined) Documentation of system reason(s) for not having cervical cancer screening performed at least once in the last three years (eg, financial reasons)


The following evidence statements are quoted verbatim from the referenced clinical guidelines. The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. (A Recommendation) (USPSTF, 2003)1 The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer. (D Recommendation) (USPSTF, 2003)1 The USPSTF recommends against routine Pap smear screening in women who have had a total hysterectomy for benign disease. (D Recommendation) (USPSTF, 2003)1 The USPSTF found no direct evidence that annual screening achieves better outcomes than screening every 3 years. (USPSTF, 2003)1 The optimal age to begin screening is unknown. Data on natural history of HPV infection and the incidence of high-grade lesions and cervical cancer suggest that screening can safely be delayed until 3 years after onset of sexual activity or until age 21, whichever comes first (ACS2). Although there is little value in screening women who have never been sexually active, many US organizations recommend routine screening by age 18 or 21 for all women, based on the generally high prevalence of sexual activity by that age in the US and concerns that clinicians may not always obtain accurate sexual histories. (USPSTF, 20031) Discontinuation of cervical cancer screening in older women is appropriate,


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provided women have had adequate recent screening with normal Pap results. The optimal age to discontinue screening is not clear, but the risk of cervical cancer and yield of screening decline steadily through middle age. The USPSTF found evidence that yield of screening was low in previously screened women after age 65. New American Cancer Society (ACS2) recommendations suggest stopping cervical cancer screening at age 70. Screening is recommended in older women who have not been previously screened, when information about previous screening is unavailable, or when screening is unlikely to have occurred in the past (eg, among women from countries without screening programs). Evidence is limited to define “adequate recent screening.” The ACS guidelines2 recommend that older women who have had three or more documented, consecutive, technically satisfactory normal/negative cervical cytology tests, and who have had no abnormal/positive cervical cytology tests within the last 10 years, can safely stop screening. (USPSTF, 20031).


Most precancers of the cervix are slow to develop. Regular cervical cancer screening can lead to early detection of almost all cases of cervical cancer. Diagnosis in the early stages of the disease when it is more responsive to treatment leads to improved survival rates3.


As reported by the American Cancer Society, the Behavioral Risk Factor Surveillance System data from 2004 show that 85% of women aged 18 years and older reported having a Pap test performed in the last three years4. A study published in 2006 found that 54.4% of women had the date and result of their last Pap smear documented in their medical record and 86.9% of women who had not had a Pap smear in the last three years had one performed5.


The measure development Work Group determined that cervical cancer screening is not indicated in all cases, such as for patients with terminal illness or patients who have a history of complete cervix removal. Therefore, a medical exclusion is included in this measure so that those patients may be excluded from the denominator. The Work Group determined that there may be patients who choose not to undergo screening or are unable to undergo screening due to financial or coverage limitations. Therefore, patient and system exclusions are also included in this measure.




• Accountability





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All female patients aged 21 through 65 years who were seen at least twice for any visits or who had at least one preventive care visit during the two-year measurement period CPT E/M Service code: Two visits during the two year measurement period

• 99201, 99202, 99203, 99204, 99205 (Office or other outpatient services-new patient)

• 99212, 99213, 99214, 99215 (Office or other outpatient services-established patient)


• 99385, 99386, 99387, 99395, 99396, 99397 (Initial comprehensive preventive medicine-new and established patient)



Numerator Patients with documentation of the performance of current* cervical cancer screening with results CPT Procedure Code for Cervical Cancer Screening:

• 88141, 88142, 88143, 88147, 88148, 88150, 88152, 88153, 88154 • 88164, 88165, 88166, 88167 • 88174, 88175

OR CPT Category II code (in development):

• 3XXXF: Cervical cancer screening results documented and reviewed


Documentation of medical reason(s) for not having cervical cancer screening performed in the last three years (eg, limited life expectancy, patient has a history of complete cervix removal)

• Append modifier to CPT Category II code: 3XXXF-1P Documentation of patient reason(s) for not having cervical cancer screening performed in the last three years (eg, patient declined)

• Append modifier to CPT Category II code: 3XXXF-2P Documentation of system reason(s) for not having cervical cancer screening performed (eg, financial reasons)



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Technical Specifications: Paper Chart Abstraction Prospective data collection flowsheets are developed for measure sets after they are approved.

References 1 U.S. Preventive Services Task Force. Screening for cervical cancer: recommendations and rationale. AHRQ Publication No. 03-515A. January 2003. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrg.gov/clinic/3rduspstf/cervcan/cervcanrr.html. Accessed November 2007. 2 Saslow D, Runowicz CD, Solomon D, Moscicki AB, Smith RA, Eyre HJ, Cohen C. American Cancer Society Guideline for the Early Detection of Cervical Neoplasia and Cancer. CA Cancer J Clin. 2002;52:342-362. 3 American Cancer Society. Cancer Facts & Figures 2008. Atlanta: American Cancer Society; 2008. 4 Smith RA, Cokkinides V, Eyre HJ. Cancer screening in the United States, 2007. A review of current guidelines, practices, and prospects. CA Cancer J Clin 2007;57:90-104. 5 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor quality health care? N Engl J Med 2006;354:1147-1156. Available at http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008.

http://www.ahrg.gov/clinic/3rduspstf/cervcan/cervcanrr.html



Measure #9: Pneumococcal Immunization Preventive Care & Screening


Measure Description Percentage of patients aged 65 years and older who have documentation of receiving pneumococcal immunization during the two-year measurement period

Measure Components

Numerator Statement

Patients who have documentation* of receiving pneumococcal immunization *Documentation may include that the patient received the immunization during that visit OR that the patient reports having previously received the immunization since age 65


All patients aged 65 years and older who were seen at least twice for any visit or who had at least one preventive care visit during the two year measurement period


Documentation of medical reason(s) for not administering pneumococcal immunization (eg, patient allergy, other contraindication) Documentation of patient reason(s) for not having received pneumococcal immunization (eg, patient declined)


The following evidence statements are quoted verbatim from the referenced clinical guidelines. Pneumococcal polysaccharide vaccine should be administered routinely to all adults 65 years of age and older. (CDC, 20071) Persons aged 65 years and older should be administered a second dose of pneumococcal vaccine if they received the vaccine more than 5 years previously, and were younger than 65 years of age at the time of the first dose. (CDC, 20071)

Rationale Relationship to desired outcome

Immunizing patients aged 65 years and older against pneumococcal disease reduces the risk of invasive disease, and associated morbidity and mortality1.


Data from the National Center for Health Statistics show that in 2005, 17.1% of adults aged 50-64 and 56.2% of adults aged 65 years and older reported ever receiving pneumococcal immunization2.


Due to the fact that this measure involves administration of a vaccination, the Work Group determined that there were justifiable medical and patient reasons for exclusion that apply to this measure.


This measure was harmonized to the extent feasible with other PCPI immunization measures, as well as the National Committee for Quality Assurance Health Effectiveness Data Information Set (HEDIS). The Standard Specifications for Immunization Measures from the National Quality Forum was also reviewed while this measure was under development.



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• Accountability


Care Setting • Ambulatory Care • Long-Term Care • Home Care





All patients aged 65 years and older who were seen at least twice for any visit or who had at least one preventive care visit during the two year measurement period CPT E/M Service code: Two visits during the two year measurement period


• 99212, 99213, 99214,99215 (Office/other outpatient services-established patient)

• 99304, 99305, 99306, 99307, 99308, 99309, 99310 (Nursing Facility Care) • 99315, 99316 (Nursing Discharge Services) • 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337

(Domiciliary, Rest Home or Custodial Care) • 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (Home

Services) OR CPT E/M Service Code: One preventive care visit during the two year measurement period





Numerator Patients who have documentation of receiving pneumococcal immunization CPT Procedure Code:

• 90732 (pneumococcal vaccine) OR CPT Category II Code:

• 4040F- Pneumococcal vaccine administered or previously received


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Documentation of medical reason(s) for not administering pneumococcal immunization (eg, patient allergy, other contraindication)

• Append modifier to CPT Category II code: 4040F-1P Documentation of patient reason(s) for not having received pneumococcal immunization (eg, patient declined)

• Append modifier to CPT Category II code: 4040F-2P



References 1 Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. 10th ed. Washington DC: Public Health Foundation, 2007. 2 National Center for Health Statistics. Health, United States, 2007: With Chartbook on Trends in the Health of Americans. Hyattsville, MD: 2007. Available at: http://www.scs.gov/nchs/hus.htm. Accessed January 2008.

http://www.scs.gov/nchs/hus.htm


Measure #10: Obesity Screening Preventive Care & Screening


Measure Description Percentage of patients aged 18 years and older for whom body mass index (BMI) is documented at least once during the two-year measurement period

Measure Components

Numerator Statement

Patients for whom body mass index (BMI) is documented


All patients aged 18 years and older who were seen at least twice for any visits or who had at least one preventive care visit during the two-year measurement period


Documentation of medical reason(s) for not documenting body mass index (BMI) (eg, patient is non-ambulatory) Documentation of patient reason(s) for not documenting body mass index (BMI) (eg, patient declined) Documentation of system reason(s) for not documenting body mass index (BMI) (eg, equipment not available)


The following evidence statements are quoted verbatim from the referenced clinical guidelines. The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. (B Recommendation) (USPSTF, 20031) A number of techniques, such as bioelectrical impedance, dual-energy x-ray absorptiometry, and total body water can measure body fat, but it is impractical to use them routinely. Body mass index (BMI), which is simply weight adjusted for height, is a more practical and widely-used method to screen for obesity. Increased BMI is associated with increase in adverse health effects. Central adiposity increases the risk for cardiovascular and other diseases independent of obesity. Clinicians may use the waist circumference as a measure of central adiposity. Men with waist circumferences greater than 102 cm (> 40 inches) and women with waist circumferences greater than 88 cm (> 35 inches) are at increased risk for cardiovascular disease. The waist circumference thresholds are not reliable for patients with a BMI greater than 35. (USPSTF, 20031) Practitioners should use the BMI to assess overweight and obesity. Body weight alone can be used to follow weight loss and to determine efficacy of therapy. (Evidence Category C) (NHLBI, 19982) The BMI should be used to classify overweight and obesity and to estimate relative risk for disease compared to normal weight. (Evidence Category C) (NHLBI, 19982) Classification of overweight and obesity by BMI: Obesity Class BMI (kg/m2)

Underweight <18

Normal 18.5-24.9


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Overweight 25.-29.9

Obesity I 30-34.9

II 35-39.9

Extreme Obesity III ≥40 Table found in: Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report (NHLBI, 1998). Adapted from: Preventing and Managing the Global Epidemic of Obesity: Report of the World Health Organization Consultation of Obesity. WHO, Geneva, June 1997

Rationale Relationship to desired outcome

Patients who are overweight or obese are at higher risk for developing hypertension, cardiovascular disease, type 2 diabetes, stroke, congestive heart failure, respiratory problems, cancer (endometrial, breast, prostate and colon), gallbladder disease and osteoarthritis2. Obesity has also been linked to patients experiencing menstrual irregularities, hirsutism, stress incontinence, and psychological disorders such as depression2. BMI is a metric that can be used to identify patients and risk, as well as guide weight management.


A 2006 study found that 66.4% of patients had a weight measurement and 40.8% of patients had height documented in the medical record at least once3. While no published data regarding a quality gap or variation in performance are available regarding how often body mass index is performed, the Work Group determined that this is an aspect of care that is not regularly performed for all patients. Through implementation and testing of this measure, it is expected that we will be able to collect data that will help us demonstrate whether or not a gap in care or variation in performance exists.


The measure development Work Group determined that the provision of preventive care and screening services—such as for patients with terminal illness—is not appropriate in all cases. Therefore, a medical exclusion is included in this measure so that those patients may be excluded from the denominator. The Work Group determined that there may be patients who choose not to undergo screening, or instances where screening may not able to be completed due to lack of equipment availability (eg, scale does not register high weights). Therefore, patient and system exclusions are also included in this measure.


This measure was harmonized to the extent feasible with the National Committee for Quality Assurance Health Effectiveness Data Information Set (HEDIS). The measure “Universal Weight Screening and Follow-Up” developed by the Pennsylvania QIO was also reviewed during the development of this measure.


• Accountability





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• 99212, 99213, 99214, 99215 (Office/other outpatient services-established patient)

• 97001, 97002 (Physical therapy evaluation) • 97003, 97004 (Occupational therapy evaluation) • 97802, 97803, 97804, G0270, G0271 (Medical Nutrition Therapy) • 98960, 98961, 98962 (Education and Training-patient self-management)






Numerator Patient for whom weight and waist circumference and/or body mass index (BMI) is documented CPTCategory II code (in development):

• 3XXXF: Body Mass Index (BMI), documented


Documentation of medical(s) reason for not documenting body mass index (BMI) (eg, patient is non-ambulatory)

• Append modifier to CPT Category II code: 3XXXF-1P Documentation of patient reason(s) for not documenting body mass index (BMI) (eg, patient declined)


Documentation of system reason(s) for not documenting body mass index (BMI) (eg, equipment not available)

Append modifier to CPT Category II code: 3XXXF-3P



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References 1 U.S. Preventive Services Task Force. Screening and interventions to prevent obesity in adults. Agency for Healthcare Research and Quality. Rockville, MD. December 2003. Available at: http://www.ahrq.gov/clinic/uspstf/uspsobes.htm. Accessed November 2007. 2 NHLBI Obesity Education Initiative Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Clinical Guidelines on the Identifcation, Evaluation, and Treatment of Overweight and Obesity in Adults – The Evidence Report. US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Heart, Lung, and Blood Institute. NIH Publication No. 98-4083. September 1998. 3 Technical Appendix to McGlynn EA, Asch SM, Adams JL, et al. Who is at greatest risk for receiving poor quality health care? N Engl J Med 2006;354:1147-1156. Available at http://www.rand.org/pubs/working_papers/WR-174-1. Accessed January 2008.

http://www.ahrq.gov/clinic/uspstf/uspsobes.htm



Guideline Evidence Classification and Rating Schemes Preventive Care & Screening

U. S. Preventive Services Task Force (USPSTF) Grades of Recommendation1,2,3 ,4 ,5 ,6 ,7 • Grade A – The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The

USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

• Grade B – – The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.

• Grade C – The USPSTF makes no recommendation for or against the routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.

• Grade D – The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.

• Grade I – The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

U.S Department of Health and Human Services/Public Health Service Strength of Evidence Ratings8 • A – Multiple well-designed randomized clinical trials, directly relevant to the recommendation, yielded a

consistent pattern of findings. • B – Some evidence from randomized clinical trials supported the recommendation, but the scientific

support was not optimal. For instance, few randomized trials existed, the trials that did exist were somewhat inconsistent, or the trials were not directly relevant to the recommendation.

• C – Reserved for important clinical situations where the panel achieved consensus on the recommendation in the absence of relevant randomized controlled trials.

References 1 U. S. Preventive Services Task Force. Counseling to prevent tobacco use and tobacco-related diseases: Recommendation statement. November 2003. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic/3rduspstf/tobaccounrs/htm. Accessed November 2007. 2 U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. April 2004. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic.3rd uspstf/alcohol/alcomisrs.htm. Accessed November 2007. 3 U.S. Preventive Services Task Force. Screening for breast cancer: recommendations and rationale. February 2002. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm. Accessed November 2007. 4 U.S Preventive Services Task Force. Screening for colorectal cancer: recommendations and rationale. July 2002. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrg.gov/clinic/3rduspstf/colorectal/colorr.htm. Accessed November 2007. 5 U.S Preventive Services Task Force. Screening for cervical cancer: recommendations and rationale. AHRQ Publication No. 03-515A. January 2003. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrg.gov/clinic/3rduspstf/cervcan/cervcanrr.html. Accessed November 2007. 6 U.S. Preventive Services Task Force. Screening for lipid disorders in adults: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication No. 08-05114-EF-2, June 2008. Agency for Healthcare Research and Quality. Rockville, MD. Available at: http://www.ahrq.gov/clinic/uspstf08/lipid/lipidrs.htm. Accessed July 2008.


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http://www.ahrq.gov/clinic/3rduspstf/tobaccounrs/htm



http://www.ahrq.gov/clinic/3rduspstf/breastcancer/brcanrr.htm

http://www.ahrg.gov/clinic/3rduspstf/colorectal/colorr.htm

http://www.ahrg.gov/clinic/3rduspstf/cervcan/cervcanrr.html

http://www.ahrq.gov/clinic/uspstf08/lipid/lipidrs.htm


7 U.S. Preventive Services Task Force. Screening and interventions to prevent obesity in adults. Agency for Healthcare Research and Quality. Rockville, MD. December 2003. Available at: http://www.ahrq.gov/clinic/uspstf/uspsobes.htm. Accessed November 2007. 8 Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.


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http://www.ahrq.gov/clinic/uspstf/uspsobes.htm



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