Docstoc

Service Visit Report Template

Document Sample
Service Visit Report Template Powered By Docstoc
					2007 Physician        Measures               Description                 Numerator
Quality Reporting     Applicable to
Initiative (PQRI)     Hospitalists
Measures (by #)
                    5 Heart Failure:         Percentage of patients       Patients who were
                      Angiotensin-           aged 18 years and older      prescribed ACE inhibitor
                      Converting Enzyme      with a diagnosis of heart    or ARB therapy
                      (ACE) Inhibitor or     failure and left ventricular
                      Angiotensin            systolic dysfunction (LVSD)
                      Receptor Blocker       who were prescribed ACE
                      (ARB) Therapy for      inhibitor or ARB therapy
                      Left Ventricular
                      Systolic Dysfunction
                      (LVSD)
6 Oral Antiplatelet    Percentage of patients     Patients who were
  Therapy Prescribed   aged 18 years and older    prescribed oral antiplatelet
  for Patients with    with a diagnosis of        therapy; Numerator
  Coronary Artery      coronary artery disease    Instructions: Oral
  Disease              who were prescribed oral   antiplatelet therapy
                       antiplatelet therapy       consists of aspirin,
                                                  clopidogrel/Plavix, or
                                                  combination of aspirin and
                                                  dypyridamole/Aggrenox.
7 Beta-blocker            Percentage of patients     Patients who were
  Therapy for CAD         aged 18 years and older    prescribed beta-blocker
  Patients with Prior     with a diagnosis of        therapy
  Myocardial Infarction   coronary artery disease
                          and prior myocardial
                          infarction (MI) who were
                          prescribed beta-blocker
                          therapy
29 Beta-blocker at       Percentage of patients with   Acute myocardial
   Time of Arrival for   a diagnosis of AMI who had    infarction patients who
   Acute Myocardial      documentation of receiving    received beta blocker
   Infarction            beta-blocker within 24        within 24 hours before or
                         hours before or after         after hospital arrival
                         hospital arrival
31 Stroke and Stroke      Percentage of patients    Patients who received
   Rehabilitation: Deep   aged 18 years and older   Deep Vein Thrombosis
   Vein Thrombosis        with a diagnosis of       (DVT) prophylaxis by the
   Prophylaxis            ischemic stroke or        end of hospital day two
                          intracranial hemorrhage   Definition: For purposes of
                          who received DVT          this measure, DVT
                          prophylaxis by end of     prophylaxis can include
                          hospital day two          Low Molecular Weight
                                                    Heparin (LMWH), Low-
                                                    Dose Unfractionated
                                                    Heparin (LDUH),
                                                    intravenous Heparin, low-
                                                    dose subcutaneous
                                                    heparin, or intermittent
                                                    pneumatic compression
                                                    devices.
32 Stroke and Stroke      Percentage of patients         Patients who were
   Rehabilitation:        aged 18 years and older        prescribed antiplatelet
   Discharged on          with a diagnosis of            therapy at discharge;
   Antiplatelet Therapy   ischemic stroke or TIA who     Definition: Antiplatelet
                          were prescribed antiplatelet   therapy: aspirin,
                          therapy at discharge           combination of aspirin and
                                                         extended-release
                                                         dipyridamole, clopidogrel,
                                                         ticlopidine
33 Stroke and Stroke         Percentage of patients         Patients who were
   Rehabilitation:           aged 18 years and older        prescribed an
   Anticoagulant             with a diagnosis of            anticoagulant at discharge
   Therapy Prescribed        ischemic stroke or TIA with    Definitions:
   for Atrial Fibrillation   documented permanent,          • Persistent Atrial
   at Discharge              persistent, or paroxysmal      Fibrillation: recurrent atrial
                             atrial fibrillation who were   fibrillation, not self-
                             prescribed an anticoagulant    terminating or terminated
                             at discharge                   electrically or
                                                            pharmacologically.
                                                            • Paroxysmal Atrial
                                                            Fibrillation: recurrent atrial
                                                            fibrillation, self-terminating
                                                            • Permanent Atrial
                                                            Fibrillation: long-standing
                                                            atrial fibrillation (>1 year),
                                                            cardioversion failed or not
                                                            attempted
34 . Stroke and Stroke    Percentage of patients      Patients who were
   Rehabilitation:        aged 18 years and older     considered for t-PA
   Tissue Plasminogen     with a diagnosis of         administration (given t-PA
   Activator Considered   ischemic stroke whose       or documented reasons
                          time from symptom onset     for patient not being a
                          to arrival is less than 3   candidate for therapy)
                          hours who were considered   Definition: For purposes of
                          for t-PA administration     this measure, patients
                                                      “considered for t-PA
                                                      administration” includes
                                                      patients to whom t-PA was
                                                      given or patients for whom
                                                      reasons for not being a
                                                      candidate for t-PA therapy
                                                      are documented.
35 Stroke and Stroke   Percentage of patients        Patients who underwent a
   Rehabilitation:     aged 18 years and older       dysphagia screening
   Screening for       with a diagnosis of           process before taking any
   Dysphagia           ischemic stroke or            foods, fluids or medication
                       intracranial hemorrhage       by mouth; Definition:
                       who underwent a               Dysphagia Screening: use
                       dysphagia screening           of a tested and validated
                       process before taking any     dysphagia screening tool
                       foods, fluids or medication   (e.g. Burke dysphagia
                       by mouth                      screening test, 3 oz. water
                                                     swallow test, Mann
                                                     assessment of swallowing
                                                     ability [MASA],
                                                     standardized bedside
                                                     swallowing assessment
                                                     [SSA]) OR a dysphagia
                                                     screening tool approved
                                                     by the hospital's
                                                     speech/language
                                                     pathology (SLP) services.
                                                     Numerator Instructions:
                                                     For purposes of this
                                                     measure, patients “who
                                                     receive any food, fluids or
                                                     medication by mouth” may
                                                     be identified by the
                                                     absence of an NPO
                                                     (nothing by mouth) order
36 Stroke and Stroke   Percentage of patients        Patients for whom
   Rehabilitation:     aged 18 years and older       consideration of
   Consideration of    with a diagnosis of           rehabilitation services
   Rehabilitation      ischemic stroke or            (ordered rehabilitation or
   Services            intracranial hemorrhage for   documented that
                       whom consideration of         rehabilitation was not
                       rehabilitation services is    indicated) is documented
                       documented                    Definition: For purposes of
                                                     this measure,
                                                     “consideration of
                                                     rehabilitation services”
                                                     includes an order for
                                                     rehabilitation services or
                                                     documentation that
                                                     rehabilitation was not
                                                     indicated.
47 Documentation of an Percentage of patients        Patients with
   Advance Care Plan aged 65 years and older         documentation of a
                       with documentation of a       surrogate decision maker
                       surrogate decision maker      or advance care plan in
                       or advance care plan in the   the medical record
                       medical record
Numerator Coding             Denominator                   Denominator Coding             Denominator
                                                                                          Exclusions


ACE Inhibitor or ARB         Heart failure patients aged   An ICD-9 diagnosis code
Therapy Prescribed           18 years and older with       for heart failure and a CPT
CPT II 4009F: Angiotensin    LVEF < 40% or with            E/M service code are
converting enzyme (ACE)      moderately or severely        required to identify
inhibitor or angiotensin     depressed left ventricular    patients for denominator
receptor blocker (ARB)       systolic function             inclusion.
therapy prescribed                                         ICD-9 diagnosis codes:
AND                                                        402.01, 402.11, 402.91
CPT II 3021F: Left                                         (hypertensive heart
ventricular ejection                                       disease with heart failure);
fraction (LVEF) <40% or                                    404.01, 404.03, 404.11,
documentation of                                           404.13, 404.91, 404.93
moderately or severely                                     (hypertensive heart and
depressed left ventricular                                 renal disease with heart
systolic function                                          failure); 428.0, 428.1,
OR                                                         428.20-428.23, 428.30-
ACE Inhibitor or ARB                                       428.33, 428.40-428.43,
Therapy not Prescribed for                                 428.9 (heart failure)
Medical, Patient, or                                       AND 13 As of: 3/29/2007
System Reasons                                             CPT E/M service codes:
Append a modifier (1P,                                     99201-99205, 99212-
2P, or 3P) to CPT                                          99215 (E/M), 99238,
Category II code 4009F to                                  99239 (discharge), 99241-
report documented                                          99245 (outpatient consult),
circumstances that                                         99304-99310 (nursing
appropriately exclude                                      facility), 99324-99328,
patients from the                                          99334-99337 (domiciliary),
denominator.                                               99341-99345, 99347-
12 As of: 3/29/2007                                        99350 (home visit)
• 1P: Documentation of
medical reason(s) for not
prescribing angiotensin
converting enzyme (ACE)
Oral Antiplatelet Therapy All patients aged 18 years      An ICD-9 diagnosis code
Prescribed                   and older with a diagnosis   for coronary artery disease
CPT II 4011F: Oral           of coronary artery disease   and a CPT E/M service
antiplatelet therapy                                      code are required to
prescribed (e.g., aspirin,                                identify patients for
clopidogrel/Plavix, or                                    denominator inclusion.
combination of aspirin and                                ICD-9 diagnosis codes:
dipyridamole/Aggrenox)                                    414.00-414.07, 414.8,
OR                                                        414.9 (coronary artery
Oral Antiplatelet Therapy                                 disease), 410.00-410.92
not Prescribed for                                        (acute myocardial
Medical, Patient, or                                      infarction); 412 (old MI),
System Reasons                                            411.0-411.89, 413.0-413.9
Append a modifier (1P,                                    (angina), V45.81
2P, or 3P) to Category II                                 (aortocoronary bypass
code 4011F to report                                      status), V45.82 (PTCA
documented                                                status)
circumstances that                                        AND
appropriately exclude                                     CPT E/M service codes:
patients from the                                         99201-99205, 99212-
denominator.                                              99215 (E/M), 99238,
• 1P: Documentation of                                    99239 (discharge), 99241-
medical reason(s) for not                                 99245 (office consult),
prescribing oral                                          99304-99310 (nursing
antiplatelet therapy (e.g.,                               facility), 99324-99328,
aspirin, clopidogrel/Plavix,                              99334-99337 (domiciliary),
or combination of aspirin                                 99341-99345, 99347-
and                                                       99350 (home visit)
dipyridamole/Aggrenox)
• 2P: Documentation of
patient reason(s) for not
prescribing oral
antiplatelet therapy (e.g.,
Beta-blocker Therapy         Patients aged 18 years       An ICD-9 diagnosis code
Prescribed                   and older with a diagnosis   to identify patients with a
CPT II 4006F: Beta-          of coronary artery disease   diagnosis of coronary
blocker therapy prescribed   who also have prior          artery disease* and a
OR                           myocardial infarction (MI)   diagnosis of myocardial
Beta-blocker Therapy not     at any time                  infarction and a CPT E/M
Prescribed for Medical,                                   service code are required
Patient, or System                                        for denominator inclusion.
Reasons                                                   ICD-9 diagnosis codes:
Append a modifier (1P,                                    414.00-414.07, 414.8,
2P, or 3P) to CPT                                         414.9, 411.0, 411.1,
Category II code 4006F to                                 411.81, 411.89, 413.0,
report documented                                         413.1, 413.9 (angina),
circumstances that                                        V45.81 (aortocoronary
appropriately exclude                                     bypass status), V45.82
patients from the                                         (PTCA status), 410.00-
denominator.                                              410.92 (acute myocardial
• 1P: Documentation of                                    infarction)*, 412 (old MI)*
medical reason(s) for not                                 AND
prescribing beta-blocker                                  Patients who had a prior
therapy                                                   MI at any time
• 2P: Documentation of                                    ICD-9 diagnosis codes:
patient reason(s) for not                                 410.00-410.92 (acute
prescribing beta-blocker                                  myocardial infarction), 412
therapy                                                   (old MI)
• 3P: Documentation of                                    AND
system reason(s) for not                                  CPT E/M service codes:
prescribing beta-blocker                                  99201-99205, 99212-
therapy                                                   99215 (E/M), 99238,
OR                                                        99239 (discharge), 99304-
Beta-blocker Therapy not                                  99310 (nursing facility),
Prescribed, Reason Not                                    99324-99328, 99334-
Specified                                                 99337 (domiciliary), 99341-
Beta-blocker Received         Patients with acute         An ICD-9 diagnosis code
G8009: Acute myocardial       myocardial infarction who   and a CPT E/M service
infarction: patient           present to hospital         code to identify patients
documented to have            inpatient setting or are    with acute myocardial
received beta-blocker at      hospitalized                infarction are required for
arrival                                                   denominator inclusion.
OR                                                        ICD-9 diagnosis codes:
Beta-blocker not Received                                 410.01, 410.11, 410.21,
for Documented Reasons                                    410.31, 410.41, 410.51,
G8011: Clinician                                          410.61, 410.71, 410.81,
documented that acute                                     410.91
myocardial infarction                                     AND
patient was not an eligible                               CPT E/M service codes:
candidate for beta-blocker                                99221-99223 (initial
at arrival measure                                        inpatient), 99218-99220,
OR                                                        99234-99236
Beta-blocker not Received                                 (observation), 99291,
G8010: Acute myocardial                                   99292 (critical care)
infarction: patient not
documented to have
received beta-blocker at
arrival
DVT Prophylaxis Received     All patients aged 18 years   An ICD-9 diagnosis code
CPT II 4070F: Deep vein      and older with the           to identify patients with a
thrombosis (DVT)             diagnosis of ischemic        diagnosis of ischemic
prophylaxis received by      stroke or intracranial       stroke or intracranial
end of hospital day 2        hemorrhage                   hemorrhage and a CPT
OR                                                        E/M service code are
DVT Prophylaxis not                                       required for denominator
Received for Medical or                                   inclusion.
Patient Reasons                                           ICD-9 diagnosis codes:
Append a modifier (1P or                                  431, 433.01, 433.11,
2P) to CPT Category II                                    433.21, 433.31, 433.81,
code 4070F to report                                      433.91, 434.01, 434.11,
documented                                                434.91, 435.9, 436, 438.2,
circumstances that                                        438.89, 438.9, 997.02
appropriately exclude                                     AND
patients from the                                         CPT E/M service codes:
denominator.                                              99221-99223 (initial
• 1P: Documentation of                                    inpatient), 99231-99233
medical reason(s) for not                                 (inpatient), 99238-99239
receiving DVT Prophylaxis                                 (discharge), 99251-99255
by end of hospital day 2,                                 (inpatient consult), 99291
including physician                                       (critical care)
documentation that patient
is ambulatory
• 2P: Documentation of
patient reason(s) for not
receiving DVT Prophylaxis
by end of hospital day 2
OR
82 As of: 3/29/2007
DVT Prophylaxis not
Received, Reason Not
Specified
Antiplatelet Therapy         All patients aged 18 years   An ICD-9 diagnosis code
Prescribed                   and older with the           to identify patients with a
CPT II 4073F: Oral           diagnosis of ischemic        diagnosis of ischemic
antiplatelet therapy         stroke or transient          stroke or transient
prescribed at discharge      ischemic attack (TIA)        ischemic attack (TIA) and
OR                                                        a CPT E/M service code
Antiplatelet Therapy                                      are required for
Prescription not                                          denominator inclusion.
Prescribed for Medical or                                 ICD-9 diagnosis codes:
Patient Reasons                                           433.01, 433.11, 433.21,
Append a modifier (1P or                                  433.31, 433.81, 433.91,
2P) to CPT Category II                                    434.01, 434.11, 434.91,
code 4073F to report                                      435.0-435.3, 435.8, 435.9,
documented                                                436, 438.2, 438.89, 438.9,
circumstances that                                        997.02
appropriately exclude                                     AND
patients from the                                         CPT E/M service codes:
denominator.                                              99218-99220 (initial
• 1P: Documentation of                                    observation care), 99221-
medical reason(s) for not                                 99223 (initial inpatient),
prescribing antiplatelet                                  99231-99233 (inpatient),
therapy at discharge,                                     99238, 99239 (hospital
including identification                                  discharge), 99251-99255
from medical record that                                  (inpatient consult), 99281-
patient on anticoagulation                                99285 (ED services),
therapy                                                   99291 (critical care)
• 2P: Documentation of
patient reason(s) for not
prescribing antiplatelet
therapy at discharge
OR
84 As of: 3/29/2007
Antiplatelet Therapy
Anticoagulant Prescribed     All patients aged 18 years   An ICD-9 diagnosis code
CPT II 4075F:                and older with the           to identify patients with a
Anticoagulant therapy        diagnosis of ischemic        diagnosis of ischemic
prescribed at discharge      stroke or transient          stroke or transient
AND                          ischemic attack (TIA) with   ischemic attack (TIA) and
CPT II 1060F:                documented permanent,        atrial fibrillation and a CPT
Documentation of             persistent, or paroxysmal    E/M service code are
permanent OR persistent      atrial fibrillation          required for denominator
OR paroxysmal atrial                                      inclusion.
fibrillation                                              ICD-9 diagnosis codes:
OR                                                        433.01, 433.11, 433.21,
86 As of: 3/29/2007                                       433.31, 433.81, 433.91,
Anticoagulant Prescription                                434.01, 434.11, 434.91,
not Received for Medical                                  435.0-435.3, 435.8, 435.9,
or Patient Reasons                                        436, 438.2, 438.89, 438.9,
Append a modifier (1P or                                  997.02
2P) to CPT Category II                                    AND
code 4075F to report                                      ICD-9 diagnosis code:
documented                                                427.31 (atrial fibrillation)
circumstances that                                        AND
appropriately exclude                                     CPT E/M service codes:
patients from the                                         99218-99220 (initial
denominator.                                              observation care), 99221-
• 1P: Documentation of                                    99223 (initial inpatient),
medical reason(s) for not                                 99231-99233 (inpatient),
prescribing anticoagulant                                 99238, 99239 (hospital
therapy at discharge                                      discharge), 99251-99255
• 2P: Documentation of                                    (inpatient consult), 99281-
patient reason(s) for not                                 99285 (ED), 99291
prescribing anticoagulant                                 (critical care)
therapy at discharge
AND
CPT II 1060F:
t-PA Administration or          All patients aged 18 years   An ICD-9 diagnosis code
Consideration Documented        and older with the           to identify patients with a
CPT II 4077F:                   diagnosis of ischemic        diagnosis of ischemic
Documentation that tissue       stroke whose time from       stroke and a CPT E/M
plasminogen activator (t-       symptom onset to arrival     service code are required
PA) administration was          is less than 3 hours.        for denominator inclusion.
considered                                                   ICD-9 diagnosis codes:
AND                                                          433.01, 433.11, 433.21,
CPT II 1065F: Ischemic                                       433.31, 433.81, 433.91,
stroke symptom onset of                                      434.01, 434.11, 434.91,
less than 3 hours prior to                                   997.02
arrival                                                      AND
OR                                                           CPT E/M service codes:
If patient does not meet                                     99218-99220 (initial
denominator inclusion                                        observation care), 99221-
because ischemic stroke                                      99223 (initial inpatient),
symptom onset ≥ 3 hours                                      99251-99255 (inpatient
prior to arrival at hospital,                                consult), 99281-99285
report:                                                      (ED services), 99291
CPT II 1066F: Ischemic                                       (critical care)
stroke symptom onset
greater than or equal to 3
hours prior to arrival
OR
89 As of: 3/29/2007
t-PA Administration or
Consideration not
Documented, Reason Not
Specified
Append a reporting
modifier (8P) to CPT
Category II code 4077F to
report circumstances
Dysphagia Screening          All patients aged 18 years   An ICD-9 diagnosis code
Conducted                    and older with the           to identify patients with a
CPT II 6010F: Dysphagia      diagnosis of ischemic        diagnosis of ischemic
screening conducted prior    stroke or intracranial       stroke or intracranial
to order for or receipt of   hemorrhage who receive       hemorrhage and a CPT
any foods, fluids or         any food, fluids or          E/M service code are
medication by mouth          medication by mouth          required for denominator
AND                                                       inclusion.
CPT II 6015F: Patient                                     ICD-9 diagnosis codes:
receiving or eligible to                                  431, 433.01, 433.11,
receive food, fluids or                                   433.21, 433.31, 433.81,
medication by mouth                                       433.91, 434.01, 434.11,
OR 91 As of: 3/29/2007                                    434.91, 435.9, 436, 438.2,
Dysphagia Screening not                                   438.89, 438.9, 997.02
Conducted for Medical                                     AND
Reasons                                                   CPT E/M service codes:
Append a modifier (1P) to                                 99218-99220 (initial
CPT Category II code                                      observation care), 99281-
6010F to report                                           99285 (ED services),
documented                                                99221-99223 (initial
circumstances that                                        inpatient), 99231-99233
appropriately exclude                                     (inpatient), 99251-99255
patients from the                                         (inpatient consult)
denominator.
• 1P: Documentation of
medical reason(s) for not
conducting dysphagia
screening prior to taking
any foods, fluids or
medication by mouth
AND
CPT II 6015F: Patient
receiving or eligible to
Rehabilitation Services       All patients aged 18 years   An ICD-9 diagnosis code
Ordered or Considered         and older with the           to identify patients with a
CPT II 4079F:                 diagnosis of ischemic        diagnosis of ischemic
Documentation that            stroke or intracranial       stroke or intracranial
rehabilitation services       hemorrhage                   hemorrhage and a CPT
were considered                                            E/M service code are
OR                                                         required for denominator
Rehabilitation Services not                                inclusion.
Ordered or Considered,                                     ICD-9 diagnosis codes:
Reason Not Specified                                       431, 433.01, 433.11,
Append a reporting                                         433.21, 433.31, 433.81,
modifier (8P) to CPT                                       433.91, 434.01, 434.11,
Category II code 4079F to                                  434.91, 435.9, 997.02
report circumstances                                       AND
when the action described                                  CPT E/M service codes:
in the numerator is not                                    99217(obsv discharge),
performed and the reason                                   99220 (initial obsv), 99221-
is not otherwise specified.                                99223 (initial inpatient),
• 8P: Rehabilitation                                       99231-99233 (inpatient),
services were not                                          99234-
considered, reason not                                     99236(obsv/inpatient),
otherwise specified                                        99238, 99239 (hospital
                                                           discharge), 99251-99255
                                                           (inpatient consult)
Surrogate Decision Maker All patients aged 65 years   A CPT E/M service code
or Advance Care Plan      and older                   to identify patients aged
Documented                                            65 years and older who
CPT II 1080F: Surrogate                               were seen by the clinician
decision maker or                                     is required for
advance care plan                                     denominator inclusion.
documented in the                                     CPT E/M service codes:
medical record                                        99201-99205, 99212-
OR                                                    99215, 99218-99220,
Surrogate Decision Maker                              99221-99223, 99231-
or Advance Directive not                              99233, 99234-99236,
Documented for Patient                                99241-99245, 99281-
Reasons                                               99285, 99291, 99292,
Append a modifier (2P) to                             99304-99310, 99324-
CPT Category II code                                  99328, 99334-99337,
1080F to report                                       99341-99345, 99347-
documented                                            99350, 99354, 99355,
circumstances that                                    99387, 99397, 99401-
appropriately exclude                                 99404
patients from the
denominator.
• 2P: Documentation of                                                             Documentation of
patient reason(s) for no                                                           patient reason(s) for
documentation of a                                                                 not documenting a
surrogate decision maker                                                           surrogate decision
or advance care plan in                                                            maker or advance
the medical record (e.g.,                                                          care plan in the
patient does not wish to                                                           medical record (eg,
discuss advance care                                                               patient does not
planning)                                                                          wish to discuss
OR                                                                                 advance care
Surrogate Decision Maker                                                           planning)
or Advance Directive not

				
DOCUMENT INFO
Description: Service Visit Report Template document sample