How to Chart for Clinical Quality Measures in PCC EHR

You can use PCC EHR to collect data for standardized measure reporting required by NCQA’s Patient Centered Medical Home (PCMH) Program or other external entities requiring clinical measure reporting from your practice. To learn more about NCQA’s standardized measure reporting, visit PCMH Standardized Measurement.

Read the article below to learn how to chart and configure your system in order to record medical information for each clinical quality measure. By following these recommendations, and training your practice on charting workflow for CQMs, you can make sure that PCC EHR records the correct data to calculate your CQM performance.

Run the Clinical Quality Measures Report and See Your Practice’s Current Results

You can report on your practice’s numbers for in your Practice Vitals Dashboard.

Clinical Quality Measures are designed to evaluate certain patient populations and compare chart activity to coding. You do not need to have a “high score” in order to qualify for the EHR Medicaid Incentive Program or to achieve PCMH recognition. The overall goal of CQM is to show improvement over time.

Pediatric CQMs Overview Chart: Adjust Your Practice’s Configuration and Visit Workflow

For a quick understanding of each measure, use the table below. You can click the “More Details” or “Show Me How” links to jump directly to a longer description, accompanied by screenshots and examples.

CMS2: Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan

This measure calculates the percentage of patients aged 12 years and older who are screened for clinical depression on the date of their 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. (CMS at eCQI)

• Denominator: PCC EHR calculates the denominator of this measure by counting all patients who had an eligible encounter code billed in the electronic encounter form during the reporting period and who were 12 or older before the reporting period. Eligible encounter codes include billed CPT codes for Sick (99202-99205, 99212-99215), Well (99384-99387, 99394-99397) Telephone Visits (98966-98968, 99441-99443), Psychotherapy (90791-90792, 90832-90837), or other counseling services.

• Numerator: PCC EHR calculates the numerator of this measure by counting all of the patients in the denominator who had a LOINC test for depression screening, generally inside a Depression Screening order, with a positive or negative result, on the encounter date. If the result was positive, the patient must have additional care in the form of a completed LOINC test for suicide risk assessment, follow-up or additional evaluation for depression, and/or a referral for depression, and/or a prescription for a depression medication, on the same date as the depression screening, in order to be included in the numerator.

• Exclusions: If a patient had an active diagnosis for Bipolar Disorder on their Problem List or in the Diagnoses component for the visit, they will be counted in the Exclusions for the measure. Some relevant codes to indicate bipolar disorder include ICD-10 code F30.— and F31.—, manic episode and bipolar disorder diagnosis codes that can used as a billed ICD-10 code. In addition, you can use SNOMED code 13746004 for bipolar disorder as a diagnosis code in the problem list or diagnosis component when charting a visit.

• Exceptions: If a patient refused the screening, or had a medical contraindication for it being performed, such as an urgent medical situation or a lack of functional capacity to complete the screening, they are excepted from the denominator (and the numerator) for the calculation and will be counted in the Exceptions for the measure. Recommended codes indicate “patient refuses to participate in or complete the depression screening” OR “documentation of medical reason for not screening patient for depression”. For example, SNOMED 183932001 (procedure contraindicated) can be linked to a “screening not done due to medical reason” screening order.

Recommended PCC EHR Configuration for CMS2 Depression Screening

In order to chart depression screenings, followup, and suicide risk assessment, your practice can create screening orders and add the specified LOINC tests or SNOMED-CT descriptions to those orders. You can also configure referral orders so that they are recorded with an appropriate SNOMED-CT. Finally, you can add the orders to chart notes so they are easy to select at every visit.

For a step-by-step procedure on how to add codes to orders and add specific orders to chart notes, read Use Orders to Track Measures for Mandates.

Configure Your Depression Screenings

Add SNOMED-CT and LOINC codes to your adolescent depression screening orders in PCC EHR.

For the initial depression screening, you should add SNOMED-CT procedure code 171207006, and LOINC test code 73831-0, “Adolescent depression screening assessment”. (You could also add LOINC 73832-8, “Adult depression screening assessment” for an order for patients 18 years or older.) The test should have a Negative/Positive result.

Code Set	Code	Description	Notes
LOINC	73831-0	Adolescent Depression Screening Assessment	Link this code to all adolescent depression screening orders
LOINC	73832-8	Adult Depression Screening Assessment	Link this code to all adult depression screening orders
SNOMED	171207006	Depression Screening	Link this code to all adolescent and adult depression screening orders

What About Other Depression Screening Tests?: Your practice might perform other depression screenings and use other LOINC tests to record discrete results. You can add more than one test to a single order. For example, if you perform a PHQ-9 at each visit, you might first add the “Adolescent depression screening assessment” test, which is used by the clinical quality measure, and then also add the “Patient Health Questionnaire 9 item (PHQ-9) total score” test in order to record the patient’s numerical result.

Configure Followup Depression Care

When a patient has a positive result on a depression screening, your practice might perform one or more additional evaluations, followup orders, or a suicide risk assessment screening order. Click “Add” to create a new screening order, or double-click on an existing order to make changes. Repeat the steps above to configure the order, and add any appropriate tests.

In order to affect the clinical quality measure for this additional evaluation, followup, or suicide risk assessment, your practice must also add SNOMED-CT procedures to the screening order. For each order, click “Add a Procedure” and search for the appropriate SNOMED-CT description.

Examples:

• Suicide Risk Assessment: For a suicide risk assessment screening order, you should add SNOMED-CT code 225337009, “Suicide risk assessment (procedure)” to the order.

• Followup For Depression: You could also create and add SNOMED-CT descriptions (and LOINC tests, if appropriate) for any number of depression followup orders, such as Completion of a Mental Health Crisis Plan, or Coping Support Management. Other options are included in the NIH’s Follow-up for depression – adolescent value set, found on the VSAC website. You can also find the “Follow-up for depression – adolescent” value set within the CMS2v4 tab of the downloaded eCQM Value Sets spreadsheet.

• Additional Evaluation: For an additional evaluation for depression order, you could add one of the SNOMED-CT descriptions for psychiatric evaluation listed by NIH for Additional evaluation for depression – adolescent. The “Additional evaluation for depression – adolescent” value set can also be found within the CMS2v4 tab of the downloaded eCQM Value Sets spreadsheet.

Configure Depression Referral Orders

Add SNOMED-CT procedures to your Referral orders for Depression.

Your practice may have one or more referrals related to depression. For example, you may have referrals for an initial psychiatric evaluation or a specific depression referral. Click “Add” to create a new order, or double-click on an existing order to make changes.

In order for the referral to be tracked as part of a clinical quality measure, you must add a SNOMED-CT description from the NIH’s list for “Referral for Depression Adolescent”.

Which Procedure Codes Can I Use for Referral Orders?: Your SNOMED-CT descriptions for depression-related referrals must be taken from the NIH’s Referral for Depression Adolescent value set, found on the VSAC website. Common selections include “Referral to psychiatry service” and “Referral for mental health counseling”. You can also find the “Referral for Depression Adolescent” value set within the CMS2v4 tab of the downloaded eCQM Value Sets spreadsheet.

Your practice may have other referrals that may follow a positive depression screening. Add new orders, or double-click on an existing order to make changes. The following table contains SNOMED codes that you can link to your follow-up on depression screening orders.

Add Depression Screening, Suicide Risk Assessment, and Referral Orders to Your Chart Note Protocols

After you make changes to the various orders your practice uses, you can add them to chart note protocols to make them easier to order. Your clinicians will then see the “Depression Screening” order, for example, on every chart note.

For information on how to add specific orders to a chart note protocol, read Use Orders to Track Measures for Mandates.

Recommended Charting and Workflow for CMS2 Depression Screening

When a patient twelve or older visits your practice, click “Order” to order a Depression Screening.

Optionally, you can assign the screening to another clinician, or complete the screening immediately. If the screening is refused, select “Refused”. If the screening is contraindicated, select “Contraindicated” and enter an appropriate contraindicated diagnosis in the Diagnoses component on the chart note.

When the screening is complete, enter a result.

Unless refused or contraindicated, a positive or negative result is required. Result interpretation, in the Interpretation field, is not required for the clinical quality measure, though your practice may have configured it to be required for completion of the order.

If the result is positive, record whatever additional care follows.

For example, you may prescribe appropriate medication, order a Suicide Risk Assessment or order a referral.

Enter results and take any other appropriate followup steps.

When you are finished charting, remember to click “Bill” and select an appropriate visit encounter code. In addition to billing, the visit encounter code is used to calculate the CQM.

CMS117: Childhood Immunization Status

This measure calculates the percentage of patients turning 2 years old during the reporting period who have a visit during the reporting period and have four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines with evidence of administration prior or on their second birthday. (CMS at eCQI)

• Denominator: PCC EHR calculates the denominator of this measure by counting all patients who turned 2 years old during the reporting period, who had an eligible encounter code entered on the electronic encounter form during the reporting period.

• Numerator: PCC EHR calculates the numerator of this measure by counting all of the patients in the denominator who have evidence of meeting all the immunization requirements, either ordered, added manually to the patient record, or billed. In order to allow for “grace periods”, the timing requirements for each immunization (three shots, four shots, etc.) require a minimum of only a single day between each shot, and allow that the shots may occur at any time between birth and age 2 after each shot’s minimum age. For example, a patient’s first DTaP must be administered when the patient is at least 42 days old, but otherwise the four shots may occur at any time before or on the patient’s 2nd birthday, as long as they are at least a day apart.

  There are numerous reasons for a patient to be included in the numerator even if they did not have a particular shot.
  • For the MMR, hepatitis B, VZV and hepatitis A vaccines, numerator inclusion criteria include: evidence of receipt of the recommended vaccine; documented history of the illness; or, a seropositive test result for the antigen.
  • For the DTaP, IPV, HiB, pneumococcal conjugate, rotavirus, and influenza vaccines, numerator inclusion criteria include only evidence of receipt of the recommended vaccine. Patients may be included in the numerator for a particular antigen if they had an anaphylactic reaction to the vaccine. Patients may be included in the numerator for the DTaP vaccine if they have encephalopathy. Patients may be included in the numerator for the IPV vaccine if they have had an anaphylactic reaction to streptomycin, polymyxin B, or neomycin.
  • Patients may be included in the numerator for the influenza, MMR, or VZV vaccines if they have cancer of lymphoreticular or histiocytic tissue, multiple myeloma, leukemia, have had an anaphylactic reaction to neomycin, have Immunodeficiency, or have HIV. Patients may be included in the numerator for the hepatitis B vaccine if they have had an anaphylactic reaction to common baker’s yeast.

• Exclusions and Exceptions: There are no across-the-board exclusions or exceptions for this measure. However, there are numerous reasons for a patient to be included in the numerator even if they did not have a particular shot. See the Numerator description above for details.
  
  The measure allows a grace period by measuring compliance with these recommendations between birth and age two. (From the “Guidance” section of CMS’s definition of the CQM.)
  
  For any immunization status exclusions, PCC checks the patient’s diagnosis history, Problem List, and Allergies List.

Recommended PCC EHR Configuration for CMS117 Childhood Immunization Status

When your practice implemented PCC software and services, the initial setup and configuration was sufficient to allow clinicians to chart in order to meet this CQM.

However, if your practice implemented PCC software before the introduction of CVX codes, which are used to uniquely identify immunizations, you may need to add them to the Immunization and Disease configuration in your PCC system. CVX codes are the industry-standard unique identifier for each vaccine or combination vaccine. Contact PCC if for help.

For more information on CVX and MVX codes in your PCC system, read CVX, MVX, VIS and NDC Codes in PCC.

What CVX Codes Are In Use?: Different combination vaccines and different formulations have different CVX codes. To review what CVX codes you administer, visit your immunization refrigerator. PCC Support can also help you compare the CVX codes in your PCC system with the CDC’s library of CVX codes. Common CVX codes for each immunization as of 2019 are as follows: DTaP 20, IPV 10, MMR 03, HIB 49, Hepatitis B 08, Varicella (chicken pox) 21, Prevnar 13 (pneumococcal conjugate PCV) 133, Hepatitis A 83, Rotavirus 116, Influenza (Flu) Preservative Free 140.

Add Age-Appropriate Immunizations to Your Custom Chart Notes

Do all of your custom chart notes have age-appropriate immunization orders ready, easy for your clinicians to click?

If not, follow the procedure below to update your chart note protocols.

Add Age-Appropriate Immunizations to Your Custom Chart Notes

Recommended Charting and Workflow for CMS117 Childhood Immunization Status

When a patient visits your practice, review their immunization history in the chart note or in the Immunization History section of the chart.

Optionally, you can review Forecasting Results and Forecasting Warnings to see what immunizations a patient may be missing.

If you need to update a patient’s past immunization history, visit the Immunization History section of the chart, click “Add Imms” and add any immunizations they received that are not in the chart record.

Use the Immunizations component on the chart note to order any age-appropriate immunizations.

Use the same component (or “Edit Orders” orange indicator tool on Schedule screen) to record that the immunization is administered, refused, contraindicated, or canceled.

When Should Each Shot Be Given?: PCC EHR can display Immunization Forecasting, with results and forecasting calculated by STC’s implementation of the ACIP immunization schedule guidelines from the CDC. Your practice may have their own set of standards for how these guidelines are implemented, and CMS has their own published clinical recommendation based on ACIP’s guidelines. The rules for reporting for the Childhood Immunization Status CQM, however, are much simpler, only requiring the correct number of shots, given more than a day apart.

If you make a decision not to give an immunization, chart the reason in the following manner:

• Contraindications: If a patient has a contraindication for an immunization, click “Contraindicated” in the order, and add the appropriate diagnosis description to the Diagnoses component in the chart note and/or to the patient’s Problem List or Allergies list. For example, if a patient has acute HIV infection, or an allergy to an immunization component, you should record that information in the Problem List and the Allergies List respectively.

• History of an Illness: If a patient has a history of an illness for which an immunization would otherwise be administered, add that illness to the patient’s Problem List or chart it in the Diagnoses component.

• Evidence of Immunity: If your practice performs titers, or receives a test result showing that the patient is seropositive for an antigen, record that result as a diagnosis or on the Problem List.

When you are finished charting, remember to click “Bill” and select an appropriate visit encounter code. In addition to billing, the visit encounter code is used to calculate the CQM.

CMS155: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

This measure calculates the percentage of patients 3-17 years of age who had had a visit during the reporting period, and had their height, weight, and body mass index (BMI) documented, and/or received counseling for nutrition, and/or received counseling for physical activity. (CMS at eCQI)

• Denominator: PCC EHR calculates the denominator of this measure by counting all patients who had an eligible encounter code billed on the electronic encounter form during the reporting period and who were between 3 and 17 years old.

• Numerator 1: PCC EHR calculates the first numerator of this measure by counting all of the patients in the denominator who had a height, weight, and BMI percentile recorded during the measurement period.

• Numerator 2: PCC EHR calculates the second numerator of this measure by counting all of the patients in the denominator who received counseling for nutrition during a visit that occurred within the measurement period.

• Numerator 3: PCC EHR calculates the third numerator of this measure by counting all of the patients in the denominator who received counseling for physical activity during a visit that occurred within the measurement period.

• Exclusions and Exceptions: Patients will be excluded from the denominator if they have an active diagnosis of pregnancy during the measurement period.

Recommended PCC EHR Configuration for CMS 155 Weight Assessment and Counseling

In order to chart counseling for nutrition or physical exercise, your practice can create medical procedure orders and add the specified SNOMED-CT procedures to those orders. Then you can add the orders to chart notes so they are easy to select at every visit.

For a step-by-step procedure on how to add codes to orders and add specific orders to chart notes, read Use Orders to Track Measures for Mandates.

Configure Your Nutrition Counseling Order

Create or edit a medical procedure order for nutrition counseling.

For the nutrition counseling order, you should select SNOMED-CT code 61310001, “Nutrition education”.

Configure Your Physical Activity Counseling Order

Create or edit a medical procedure order for physical activity counseling.

For the physical activity counseling order, you should select SNOMED-CT code 281090004, “Recommendation to exercise”.

Use the Specified SNOMED Codes: Please note that the 2018 ICD-10 code Z71.82, “Exercise counseling” will not work with PCC EHR reporting.

Add Nutrition and Physical Activity Counseling Orders to Your Chart Note Protocols

After you create the new medical procedure orders, you can add them to chart note protocols to make them easier to order. Your clinicians will then see the “Nutrition Counseling” order, for example, on every chart note.

For detailed instructions on how to add orders to a chart note protocol, read Use Orders to Track Measures for Mandates.

For each protocol, find or add the Medical Procedures Orders component, and then add the nutrition and physical exercise orders.

Recommended Charting and Workflow for CMS 155 Weight Assessment and Counseling

Collect height and weight during normal office visits, well exams and other appropriate visit types.

When appropriate, order your practice’s nutrition and/or physical activity counseling medical procedure.

When you are finished charting, remember to click “Bill” and select an appropriate visit encounter code. In addition to billing, the visit encounter code is used to calculate the CQM.

PCC’s Current Certification Status and Required CQMs for PCMH

PCC EHR is Prevalidated for PCMH: By using PCC EHR, your practice is pre-validated for automatic credits towards PCMH recognition. Many pediatric practices have used PCC to achieve PCMH recognition.

Please contact PCC for help understanding and applying for PCMH programs in your state. PCC Support and our Pediatric Solutions team can show you what you need to apply and help you evaluate your options.

What CQMs Are You Required to Report On

You have several options for reporting on Clinical Quality Measures at your practice, depending on whether you applied for the EHR Medicaid Incentive Program or are applying for PCMH recognition.

Learn About PCMH Programs: Just getting started? Read Become a Patient Centered Medical Home (PCMH).

CQMs that Were Required for the EHR Medicaid Incentive Program

When you completed your Meaningful Use attestation each year, you calculated and submitted each clinician’s numbers for 9 Clinical Quality Measures, from a total of 64. Those nine measures needed to be drawn from at least three of six domains (Patient and Family Engagement, Population/Public Health, Patient Safety, Care Coordination, Efficient Use of Healthcare Resources, Clinical Process/Effectiveness).

In order to simplify the selection of measures, CMS identified a set of 9 CQMs for pediatric populations that meet all the requirements of the program. These recommended measures “focus on conditions that contribute to the morbidity and mortality of most Medicaid beneficiaries. They also focus on areas that represent national public health priorities or disproportionately drive health care costs.” (CMS.gov)

PCC built charting and workflow technologies, and our CQM report, around these 9 recommended pediatric CQMs.

Below are the 9 measures for which PCC EHR tracks and provides calculations under the EHR Medicaid Incentive Program 2014-edition CQM rules:

• CMS2: Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan

• CMS75: Children Who Have Dental Decay or Cavities

• CMS117: Childhood Immunization Status

• CMS126: Use of Appropriate Medications for Asthma

• CMS136: ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication

• CMS146: Appropriate Testing for Children with Pharyngitis

• CMS153: Chlamydia Screening for Women

• CMS155: Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents

• CMS154: Appropriate Treatment for Children with Upper Respiratory Infection (URI)

While you consider workflow and configuration adjustments, remember that there is no threshold for these measures; the program required that clinicians simply submit data as it pertains to each CQM.

CQMs for PCMH

There are many different ways a pediatric practice can achieve PCMH recognition. Reporting on CQM measures is not required. That being said, reporting on Clinical Quality Measures can help you complete element 6a of your PCMH application. It would be very difficult to proceed beyond PCMH recognition level 1 or level 2 without CQM reporting.

Element 6a requires that a practice measures and receives data on at least two immunization measures, at least two other preventive care measures, and at least three chronic or acute care clinical measures. Additionally, the performance data must be stratified for vulnerable populations.

The nine Pediatric CQMs described in the “CQMs For Meaningful Use” section above, and available in PCC EHR’s Clinical Quality Measures report, meet or exceed these requirements. However, your practice could choose other measures.

For example, you could use PCC’s Practice Vitals Dashboard to report on:

• Seasonal flu vaccine rates (vaccine measure)
• Asthma patients up-to-date on flu vaccine (vaccine measure)
• ADHD Followup Rate (chronic/acute measure)
• Well Visit Rates (preventive measure)
• Developmental screening rates (preventive measure)

For your PCMH application, your practice could use the 9 CMS recommended CQMs that are described in this document, or use data from Practice Vitals Dashboard to report on other CQMs, or use an entirely different set of CQMs, or forego CQM reporting altogether and aim for a lower level of PCMH recognition.