Dementia: Cognitive Assessment (2021)

eCQMs / NQF #: CMS149v9 / 2872e
Measure: Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
Numerator: Patients for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period.
Denominator: All patients, regardless of age, with a diagnosis of dementia.
Denominator Exceptions:   Documentation of patient reason(s) for not assessing cognition.
Domain: Effective Clinical Care

 

In ChartMaker Clinical:

In order to qualify for this measure, the provider must have seen the patient at least twice during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator: 

ICD-10:  
Code Description
A52.17 General paresis
F01.50 Vascular dementia without behavioral disturbance
F01.51 Vascular dementia with behavioral disturbance
F02.80 Dementia in other diseases classified elsewhere without behavioral disturbance
F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance
F03.90 Unspecified dementia without behavioral disturbance
F03.91 Unspecified dementia with behavioral disturbance
F05 Delirium due to known physiological condition
F06.8 Other specified mental disorders due to known physiological condition
G30.0 Alzheimer’s disease with early onset
G30.1 Alzheimer’s disease with late onset
G30.8 Other Alzheimer’s disease
G30.9 Alzheimer’s disease, unspecified
G31.01 Pick’s disease
G31.09 Other frontotemporal dementia
G31.83 Dementia with Lewy bodies

 

SNOMED:  
Code Description
10349009 Multi-infarct dementia with delirium (disorder)
10532003 Primary degenerative dementia of the Alzheimer type, presenile onset, with depression (disorder)
111480006 Psychoactive substance-induced organic dementia (disorder)
12348006 Presenile dementia (disorder)
14070001 Multi-infarct dementia with depression (disorder)
15662003 Senile dementia (disorder)
191449005 Uncomplicated senile dementia (disorder)
191451009 Uncomplicated presenile dementia (disorder)
191452002 Presenile dementia with delirium (disorder)
191454001 Presenile dementia with paranoia (disorder)
191455000 Presenile dementia with depression (disorder)
191457008 Senile dementia with depressive or paranoid features (disorder)
191458003 Senile dementia with paranoia (disorder)
191459006 Senile dementia with depression (disorder)
191461002 Senile dementia with delirium (disorder)
191463004 Uncomplicated arteriosclerotic dementia (disorder)
191464005 Arteriosclerotic dementia with delirium (disorder)
191465006 Arteriosclerotic dementia with paranoia (disorder)
191466007 Arteriosclerotic dementia with depression (disorder)
191493005 Drug-induced dementia (disorder)
22381000119105 Primary degenerative dementia (disorder)
230258005 Amyotrophic lateral sclerosis with dementia (disorder)
230270009 Frontotemporal dementia (disorder)
230282000 Post-traumatic dementia (disorder)
230283005 Punch drunk syndrome (disorder)
230285003 Vascular dementia of acute onset (disorder)
230286002 Subcortical vascular dementia (disorder)
230287006 Mixed cortical and subcortical vascular dementia (disorder)
230288001 Semantic dementia (disorder)
230289009 Patchy dementia (disorder)
25772007 Multi-infarct dementia with delusions (disorder)
26852004 Primary degenerative dementia of the Alzheimer type, senile onset, with depression (disorder)
278857002 Dementia of frontal lobe type (disorder)
279982005 Cerebral degeneration presenting primarily with dementia (disorder)
281004 Dementia associated with alcoholism (disorder)
31081000119101 Presenile dementia with delusions (disorder)
312991009 Senile dementia of the Lewy body type (disorder)
32875003 Inhalant-induced persisting dementia (disorder)
371024007 Senile dementia with delusion (disorder)
371026009 Senile dementia with psychosis (disorder)
416780008 Primary degenerative dementia of the Alzheimer type, presenile onset (disorder)
420614009 Organic dementia associated with acquired immunodeficiency syndrome (disorder)
421023003 Presenile dementia associated with acquired immunodeficiency syndrome (disorder)
421529006 Dementia associated with acquired immunodeficiency syndrome (disorder)
425390006 Dementia associated with Parkinson’s Disease (disorder)
429458009 Dementia due to Creutzfeldt Jakob disease (disorder)
429998004 Vascular dementia (disorder)
430771000124100 Moderate dementia (disorder)
442344002 Dementia due to Huntington chorea (disorder)
4817008 Primary degenerative dementia of the Alzheimer type, senile onset, with delirium (disorder)
51928006 General paresis – neurosyphilis (disorder)
52448006 Dementia (disorder)
54502004 Primary degenerative dementia of the Alzheimer type, presenile onset, with delusions (disorder)
55009008 Primary degenerative dementia of the Alzheimer type, senile onset, with delusions (disorder)
56267009 Multi-infarct dementia (disorder)
59651006 Sedative, hypnotic AND/OR anxiolytic-induced persisting dementia (disorder)
62239001 Parkinson-dementia complex of Guam (disorder)
6475002 Primary degenerative dementia of the Alzheimer type, presenile onset, uncomplicated (disorder)
65096006 Primary degenerative dementia of the Alzheimer type, presenile onset, with delirium (disorder)
66108005 Primary degenerative dementia of the Alzheimer type, senile onset, uncomplicated (disorder)
698624003 Dementia associated with cerebral lipidosis (disorder)
698625002 Dementia associated with normal pressure hydrocephalus (disorder)
698626001 Dementia associated with multiple sclerosis (disorder)
698687007 Post-traumatic dementia with behavioral change (disorder)
698725008 Dementia associated with neurosyphilis (disorder)
698726009 Dementia associated with viral encephalitis (disorder)
698781002 Dementia associated with cerebral anoxia (disorder)
702393003 Frontotemporal dementia with gene located on 3p11 (disorder)
702426001 GRN-related frontotemporal dementia (disorder)
702429008 Frontotemporal dementia with parkinsonism-17 (disorder)
703544004 Inclusion body myopathy with early-onset Paget disease and frontotemporal dementia (disorder)
70936005 Multi-infarct dementia, uncomplicated (disorder)
713488003 Presenile dementia co-occurrent with human immunodeficiency virus infection (disorder)
713844000 Dementia co-occurrent with human immunodeficiency virus infection (disorder)
715737004 Parkinsonism co-occurrent with dementia of Guadeloupe (disorder)
716667005 Right temporal atrophy variant frontotemporal dementia (disorder)
716994006 Behavioral variant of frontotemporal dementia (disorder)
722977005 Dementia co-occurrent and due to neurocysticercosis (disorder)
722978000 Dementia caused by toxin (disorder)
722979008 Dementia due to metabolic abnormality (disorder)
722980006 Dementia due to chromosomal anomaly (disorder)
723123001 Ischemic vascular dementia (disorder)
723390000 Rapidly progressive dementia (disorder)
724776007 Dementia due to disorder of central nervous system (disorder)
724777003 Dementia due to infectious disease (disorder)
724992007 Epilepsy co-occurrent and due to dementia (disorder)
725898002 Delirium co-occurrent with dementia (disorder)
733184002 Dementia caused by heavy metal exposure (disorder)
733185001 Dementia following injury caused by exposure to ionizing radiation (disorder)
733190003 Dementia due to primary malignant neoplasm of brain (disorder)
733191004 Dementia due to chronic subdural hematoma (disorder)
733192006 Dementia due to herpes encephalitis (disorder)
733193001 Dementia co-occurrent and due to progressive multifocal leukoencephalopathy (disorder)
733194007 Dementia co-occurrent and due to Down syndrome (disorder)
762350007 Dementia due to prion disease (disorder)
762351006 Dementia due to and following injury of head (disorder)
762707000 Subcortical dementia (disorder)
79341000119107 Mixed dementia (disorder)
82959004 Dementia paralytica juvenilis (disorder)
90099008 Subcortical leukoencephalopathy (disorder)
9345005 Dialysis dementia (disorder)

This is captured by adding a procedure with a valid CPT or SNOMED code using the Procedure widget in a note.

CPT:    
Code Description
90791 Psychiatric diagnostic evaluation
90792 Psychiatric diagnostic evaluation with medical services
90832 Psychotherapy, 30 minutes with patient
90834 Psychotherapy, 45 minutes with patient
90837 Psychotherapy, 60 minutes with patient
96116 Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, [eg, acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities]), by physician or other qualified health care professional, both face-to-face time with the patient and time interpreting test results and preparing the report; first hour
97165 Occupational therapy evaluation, low complexity, requiring these components: An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem; An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component. Typically, 30 minutes are spent face-to-face with the patient and/or family.
97166 Occupational therapy evaluation, moderate complexity, requiring these components: An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 45 minutes are spent face-to-face with the patient and/or family.
97167 Occupational therapy evaluation, high complexity, requiring these components: An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance; An assessment(s) that identifies 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component. Typically, 60 minutes are spent face-to-face with the patient and/or family.
97168 Re-evaluation of occupational therapy established plan of care, requiring these components: An assessment of changes in patient functional or medical status with revised plan of care; An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 10 minutes are spent face-to-face with the patient and/or family.
99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 25 minutes are spent face-to-face with the patient and/or family.
99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99241 Office consultation for a new or established patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Typically, 15 minutes are spent face-to-face with the patient and/or family.
99242 Office consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99243 Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.
99244 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
99125 Office consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 80 minutes are spent face-to-face with the patient and/or family.
99304 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of low severity. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99305 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99306 Initial nursing facility care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the problem(s) requiring admission are of high severity. Typically, 45 minutes are spent at the bedside and on the patient’s facility floor or unit.
99307 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 10 minutes are spent at the bedside and on the patient’s facility floor or unit.
99308 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 15 minutes are spent at the bedside and on the patient’s facility floor or unit.
99309 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient has developed a significant complication or a significant new problem. Typically, 25 minutes are spent at the bedside and on the patient’s facility floor or unit.
99310 Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 35 minutes are spent at the bedside and on the patient’s facility floor or unit.
99315 Nursing facility discharge day management; 30 minutes or less
99316 Nursing facility discharge day management; more than 30 minutes
99318 Evaluation and management of a patient involving an annual nursing facility assessment, which requires these 3 key components: A detailed interval history; A comprehensive examination; and Medical decision making that is of low to moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Typically, 30 minutes are spent at the bedside and on the patient’s facility floor or unit.
99324 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent with the patient and/or family or caregiver.
99325 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient and/or family or caregiver.
99326 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent with the patient and/or family or caregiver.
99327 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of high severity. Typically, 60 minutes are spent with the patient and/or family or caregiver.
99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant new problem requiring immediate physician attention. Typically, 75 minutes are spent with the patient and/or family or caregiver.
99334 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self-limited or minor. Typically, 15 minutes are spent with the patient and/or family or caregiver.
99335 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low to moderate severity. Typically, 25 minutes are spent with the patient and/or family or caregiver.
99336 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent with the patient and/or family or caregiver.
99337 Domiciliary or rest home visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive interval history; A comprehensive examination; Medical decision making of moderate to high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. The patient may be unstable or may have developed a significant new problem requiring immediate physician attention. Typically, 60 minutes are spent with the patient and/or family or caregiver.
99341 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Typically, 20 minutes are spent face-to-face with the patient and/or family.
99342 Home visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.
99343 Home visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
SNOMED:    
Code Description
10197000 Psychiatric interview and evaluation (procedure)
165172002 Diagnostic psychiatric interview (procedure)
17436751 Medical consultation with outpatient (procedure)
18170008 Subsequent nursing facility visit (procedure)
183381005 General psychotherapy (regime/therapy)
183382003 Psychotherapy – behavioral (regime/therapy)
183383008 Psychotherapy – cognitive (regime/therapy)
18512000 Individual psychotherapy (regime/therapy)
185316757 Indirect encounter (procedure)
185317003 Telephone encounter (procedure)
185318008 Third party encounter (procedure)
185320006 Encounter by computer link (procedure)
185321005 Letter encounter to patient (procedure)
185467508 Home visit request by patient (procedure)
185462000 Home visit request by relative (procedure)
185466752 Home visit for urgent condition (procedure)
185467006 Home visit for acute condition (procedure)
185468001 Home visit for chronic condition (procedure)
185470005 Home visit elderly assessment (procedure)
185349003 Encounter for check up (procedure)
185463005 Visit out of hours (procedure)
185464004 Out of hours visit – not night visit (procedure)
185465003 Weekend visit (procedure)
207195004 History and physical examination with evaluation and management of nursing facility patient (procedure)
209099002 History and physical examination with management of domiciliary or rest home patient (procedure)
210098006 Domiciliary or rest home patient evaluation and management (procedure)
225929007 Joint home visit (procedure)
270424005 Letter encounter from patient (procedure)
270427003 Patient-initiated encounter (procedure)
270430005 Provider-initiated encounter (procedure)
281036757 Follow-up consultation (procedure)
302242004 Long-term psychodynamic psychotherapy (regime/therapy)
30346759 Evaluation and management of established outpatient in office or other outpatient facility (procedure)
304820009 Developmental psychodynamic psychotherapy (regime/therapy)
304822001 Psychodynamic-interpersonal psychotherapy (regime/therapy)
307808008 Neuropsychological testing (procedure)
308335008 Patient encounter procedure (procedure)
308720009 Letter encounter (procedure)
314034001 Psychodynamic psychotherapy (regime/therapy)
315205008 Bank holiday home visit (procedure)
3391000175108 Office visit for pediatric care and assessment (procedure)
37894004 Evaluation and management of new outpatient in office or other outpatient facility (procedure)
386473003 Telephone follow-up (procedure)
38678006 Client-centered psychotherapy (regime/therapy)
390906757 Follow-up encounter (procedure)
401157001 Brief solution focused psychotherapy (regime/therapy)
401267002 Telephone triage encounter (procedure)
401271004 E-mail sent to patient (procedure)
406547006 Urgent follow-up (procedure)
410155007 Occupational therapy assessment (procedure)
410157004 Occupational therapy management (procedure)
438515009 E-mail encounter from carer (procedure)
438516755 E-mail encounter to carer (procedure)
439708006 Home visit (procedure)
439740005 Postoperative follow-up visit (procedure)
443730003 Interpersonal psychotherapy (regime/therapy)
445450000 Encounter by short message service text messaging (procedure)
448337001 Telemedicine consultation with patient (procedure)
68338001 Interactive medical psychiatric diagnostic interview (procedure)
698704008 Home visit for rheumatology service (procedure)
704126758 Home visit for anticoagulant drug monitoring (procedure)
75516751 Psychotherapy (regime/therapy)
77406758 Confirmatory medical consultation (procedure)
79094001 Initial psychiatric interview with mental status and evaluation (procedure)
87790002 Follow-up inpatient consultation visit (procedure)
90102008 Social psychotherapy (regime/therapy)
90526750 Initial evaluation and management of healthy individual (procedure)

Denominator Exceptions: 

This can be captured in the Screening dialog, by selecting a reason in the Screening not done for patient reason drop-down list of the Blessed Orientation Memory Concentration Test (Cognitive Assessment) screening.

 

Required Data Elements for the Numerator: 

This can be captured by completing the Blessed Orientation Memory Concentration Test (Cognitive Assessment) via the Screening widget.

 

The questionnaire is accessed by clicking the corresponding button at the top of the dialog. After the questionnaire is accessed, you can configure the answers for the various questions. Do note if the answer to the first question (Screening not done for patient reason), is anything other than No or blank (unanswered), the assessment questionnaire sections below will be grayed out and no score will be given.

The Repeat the memory phrase… link provides access to detailed information on how to score this aspect of the questionnaire.

The various assessment questions have a measured Total Score based on the answered questions allowing you to quickly determine if the patient assessment is consistent with dementia and thereby offer further testing or treatment as needed. If you click the Total Score link, additional information is provided about how the scoring is conducted.

The Note Output options at the bottom of the dialog provides you with choices to determine how this information is outputted to the note. You can choose to output only the Title, to output the configured information in List format, or to output the configured information in Paragraph format, or to output the Title & Score.

ADDITIONAL INFORMATION:

  • Cognition can be assessed by the clinician during the patient’s clinical history.
  • The only data used to determine the denominator is data from ChartMaker Clinical. If a patient encounter was not entered into Clinical, that encounter is not included in the denominator for the statistical calculations on the MIPS Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.