Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP).

Measurement Period: January 1 - December 31

Description:
The percentage of adults 66 years and older who had each of the following during the measurement period:

• Medication review. 
• Functional status assessment.*

Provider Specialty: Prescribing practitioner or clinical pharmacist.

Measure Reporting: CMS Start Rating Measure.

Improvement Notation: Increased score indicates improvement.

Data Collection:

• Administrative.
• Hybrid.
• Supplemental.

Initial Population:

• Measure Item Count: Person.
• Age: 66 years of age and older as of the last day of the measurement period.
• Benefits: Medical.
• Continuous Enrollment: The measurement period.
• Allowable Gap: No more than one gap of ≤45 days during the measurement period. No gaps on the last day of the measurement period.

Definition:
Medication list: A list of medications in the medical record. May include medication names, or may include dosages, frequency, over-the-counter (OTC) medications and herbal or supplemental therapies.

Medication review: A review of all the person’s medications, including prescription medications, OTC medications and herbal or supplemental therapies.

Standardized tool: A set of structured questions that elicit the person’s information. May include person-reported outcome measures, screening or assessment tools or standardized questionnaires developed by the health plan to assess risks and needs.

Denominator:
The initial population minus denominator exclusions.

Numerator:
Numerator 1 - Medication review.
Either of the following meets numerator criteria:

• Both of the following during the same visit during the measurement period where the provider type is a prescribing practitioner or clinical pharmacist:
  
  • At least one medication review.
  • The presence of a medication list in the medical record.
  • Transitional care management services during the measurement period.

Numerator 2 -  Functional status assessment.
Functional status assessment during the measurement period.

Best Practice and Measure Tips

Medication review

• A medication list, signed and dated during the measurement year meets criteria:  The practitioner’s signature is considered evidence that the medications were reviewed. 
• Review and List of the member’s medications in the medical record: May include medication names only or may include medication names, dosages and frequency, over-the-counter (OTC) medications and herbal or supplemental therapies. 
• Medical record: Documentation must come from the same medical record and must include one of the following:
  
  • A medication list in the medical record and evidence of a medication review by a prescribing practitioner or clinical pharmacist and the date when it was performed. 
  • Notation that the person is not taking any medication and the date when it was noted.
• A medication review performed without the member present meets criteria.

Functional status assessment
A complete functional status assessment must include one of the following:

• Notation that Activities of Daily Living (ADL) were assessed or
• Notation that at least five of the following were assessed:
  • Bathing, dressing, eating, transferring [e.g., getting in and out of chairs], using toilet, walking.
• Notation that Instrumental Activities of Daily Living (IADL) were assessed or
• Notation that at least four of the following were assessed:
  • Shopping for groceries, driving or using public transportation, using the telephone, cooking or meal preparation, housework, home repair, laundry, taking medications, handling finances. •    
• Documentation in the medical record must include evidence of a complete functional status assessment and the date when it was performed.
• A functional status assessment limited to an acute or single condition, event or body system (e.g., lower back, leg) does not meet criteria for a comprehensive functional status assessment.
• The components of the functional status assessment numerator may take place during separate visits within the measurement year.
• Do not include comprehensive functional status assessments performed in an acute inpatient setting.
• A set of structured questions that elicit member information may be helpful.   May include person-reported outcome measures, screening or assessment tools or standardized questionnaires. 
• Result of assessment using a standardized functional status assessment tool, not limited to:
  • SF-36®.
  • Assessment of Living Skills and Resources (ALSAR).
  • Barthel ADL Index Physical Self-Maintenance (ADLS) Scale.
  • Bayer ADL (B-ADL) Scale.
  • Barthel Index.
  • Edmonton Frail Scale.
  • Extended ADL (EADL) Scale.
  • Groningen Frailty Index.
  • Independent Living Scale (ILS).
  • Katz Index of Independence in ADL.
  • Kenny Self-Care Evaluation.
  • Klein-Bell ADL Scale.
  • Kohlman Evaluation of Living Skills (KELS).
  • Lawton & Brody’s IADL scales.
  • Patient Reported Outcome Measurement Information System (PROMIS) Global or Physical Function Scales.

Measure Exclusions

Denominator Exclusions: 

• Persons in hospice or using hospice services any time during the measurement period.
• Exclude services provided in an acute inpatient setting.
• Persons who died any time during the measurement period.

Numerator Exclusions:
Numerator 1 - Medication review.

• A review of side effects for a single medication at the time of prescription alone is not sufficient.
• Medication lists or medication reviews performed in an acute inpatient setting.

Numerator 2 - Functional status assessment.

• A functional status assessment limited to an acute or single condition, event or body system (e.g., lower back, leg) does not meet criteria for a comprehensive functional status assessment.
• Comprehensive functional status assessments performed in an acute inpatient setting.

Measure Codes

Medication review:  

• CPT: 90863, 99483, 99605, 99606  
• CPT II: 1160F
• SNOMED CT US Edition: 719327002, 719328007, 719329004, 461651000124104

Medication List:

• CPT II: 1159F
• HCPCS: G8427
• SNOMED CT US Edition: 428191000124101, 432311000124109

Transitional Care Management Services 

• CPT: 99495, 99496

Functional status assessment    

• CPT: 99483
• CPT II: 1170F
• HCPCS: G0438, G0439
• SNOMED CT US Edition: 304492001, 385880002