2014 Physician Quality Reporting System (PQRS) 01/23/2014
Measures List Adapted for LSCW's with QDC codes
National
Quality
Strategy
Domain
NQF
#
PQRS
#
N/A
0103
106
Effective
Clinical Care
CMS16
1v2
0104
107
Effective
Clinical Care
Measure Description
Adult Major Depressive Disorder (MDD):
Comprehensive Depression Evaluation:
Diagnosis and Severity: Percentage of
patients aged 18 years and older with a new
diagnosis or recurrent episode of major
depressive disorder (MDD) with evidence that
they met the Diagnostic and Statistical Manual
of Mental Disorders (DSM)-5 criteria for MDD
AND for whom there is an assessment of
depression severity during the visit in which a
new diagnosis or recurrent episode was
identified
Adult Major Depressive Disorder (MDD):
Suicide Risk Assessment: Percentage of
patients aged 18 years and older with a
diagnosis of major depressive disorder (MDD)
with a suicide risk assessment completed
during the visit in which a new diagnosis or
recurrent episode was identified
Measure
Developer
Reporting
Options
Frequency
e-Msr
ID
QDC
CODES
AMA-PCPI
Claims,
Registry
Once
per
year
1040F: for MDD
documented at the
initial evaluation;
or
G8930
:for assessment of
depression
severity at the
initial evaluation
AMA-PCPI
Claims,
Registry, EHR
Once
per
year
G8932 for suicide
risk assessed at
the initial
evaluation;
3092F for major
depressive
disorder
in remission;
G8933 for suicide
risk not assessed
at the initial
evaluation
NQF
#
PQRS
#
CMS68
v3
0419
130
Patient
Safety
CMS2v
3
0418
134
GPR
O
PRE
V-12
Community/
Population
Health
Measure Description
Documentation of Current Medications in
the Medical Record: Percentage of visits for
patients aged 18 years and older for which the
eligible professional attests to documenting a
list of current medications using all immediate
resources available on the date of the
encounter. This list must include ALL known
prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements
AND must contain the medications’ name,
dosage, frequency and route of administration
Preventive Care and Screening: Screening
for Clinical Depression and Follow-Up Plan:
Percentage of patients aged 12 years and older
screened for clinical depression on the date of
the encounter using an age appropriate
standardized depression screening tool AND if
positive, a follow-up plan is documented on the
date of the positive screen
©Joseph G. Lynch LCSW April 2014 Adapted from CMS
Measure
Developer
Reporting
Options
Frequency
National
Quality
Strategy
Domain
e-Msr
ID
QDC
CODES
CMS
Claims,
Registry, EHR,
Measures
Groups,
(Oncology
Each
visit
G8427:
Current
Medications
Documented
G8430:
Current
Medications not
Documented
CMS
Claims,
Registry, EHR,
GPRO Web
Interface/ACO
Once
per
year
G8431:
Positive screen for
clinical depression with
a documented follow
up planG8510: Negative
screen for clinical
depression, follow -up
not required;
G8433:Screening for
clinical depression
not documented,
patient not
eligible/
appropriate
G8940Screening for
clinical
depression
documented, follow-up
plan –no
National
Quality
Strategy
Domain
NQF
#
PQRS
#
N/A
AQA
adopt
ed
173
Community/
Population
Health
Preventive Care and Screening: Unhealthy
Alcohol Use – Screening: Percentage of
patients aged 18 years and older who were
screened for unhealthy alcohol use at least
once within 24 months using a systematic
screening method
AMA-PCPI
Registry,
Measures
Group (Prev
Care
Once
a
year
3016F: Patient
screened for unhealthy
alcohol use using a
systematic screening
method
3016F-1P:unhealthy
alcohol use screening
not performed, for
medical reasons,
document reason for
no screening
3016F-8P:unhealthy
alcohol use screening
not
performed, reason not
otherwise specified
G8732, i.e., pain
assessment not
documented, no
reason given
N/A
AQA
adopt
ed
181
Patient
Safety
Elder Maltreatment Screen and Follow-Up
Plan: 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
CMS
Claims,
Registry
Once
per
year
G8733:
Documentation of a
positive elder
maltreatment screen
and documented
follow-up plan at the
time of the positive
screen
G8734: Elder
maltreatment screen
documented as
negative
Measure Description
©Joseph G. Lynch LCSW April 2014 Adapted from CMS
Measure
Developer
Reporting
Options
Frequency
e-Msr
ID
QDC
CODES
NQF
#
PQRS
#
CMS13
8v2
0028
226
GPR
O
PRE
V-10
Community/
Population
Health
Preventive Care and Screening: Tobacco
Use: Screening and Cessation Intervention:
Percentage of patients aged 18 years and older
who were screened for tobacco use one or
more times within 24 months AND who
received cessation counseling intervention if
identified as a tobacco user
AMA-PCPI
247
Effective
Clinical Care
Substance Use Disorders: Counseling
Regarding Psychosocial and Pharmacologic
Treatment Options for Alcohol Dependence:
Percentage of patients aged 18 years and older
with a diagnosis of current alcohol dependence
who were counseled regarding psychosocial
AND pharmacologic treatment options for
alcohol dependence within the 12-month
reporting period
AMAPCPI/NCQA
N/A
AQA
adopt
ed
Measure Description
©Joseph G. Lynch LCSW April 2014 Adapted from CMS
Measure
Developer
Reporting
Options
Claims,
Registry, EHR,
GPRO Web
Interface/ACO,
Measures
Groups (CAD,
COPD, HF,
IBD, IVD, Prev
Care, HTN,
Cardiovascular
Prevention,
Oncology)
Claims,
Registry
Frequency
National
Quality
Strategy
Domain
e-Msr
ID
QDC
CODES
Once 4004F: Patient0028
screened for
per
year tobacco use AND
received tobacco
cessation
intervention
(counseling,
pharmacotherapy, or
both), if identified as
a tobacco user
1036F: Current
tobacco nonuser;
patient screened for
tobacco use and
Identified as
a non-user of
Tobacco
4320F:
assessment of
psychosocial and
pharmacologic
treatment options
for alcohol
dependence
N/A
NQF
#
PQRS
AQA
adopt
ed
248
#
National
Quality
Strategy
Domain
Effective
Clinical Care
Measure Description
Substance Use Disorders: Screening for
Depression Among Patients with Substance
Abuse or Dependence: Percentage of patients
aged 18 years and older with a diagnosis of
current substance abuse or dependence who
were screened for depression within the 12month reporting period
©Joseph G. Lynch LCSW April 2014 Adapted from CMS
Measure
Developer
AMAPCPI/NCQA
Reporting
Options
Claims,
Registry
Frequency
e-Msr
ID
QDC
CODES
1220F: screening
for depression
among patients
with substance
abuse or
dependence (see
#134 for screening
tools)
1220F1P:screening for
depression among
patients with
substance abuse
or
dependence not
completed for
medical reasons,
documentation
required.