CMS156v10 – Use of High-Risk Medications in the Elderly

Patients 65 years and older who had a visit during the measurement period.

– NUMERATOR 

Rate 1: Patients with at least two orders of high-risk medications from the same drug class.

Rate 2: Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines).

Rate 3: Total rate (the sum of the two previous numerators, deduplicated).

– NUMERATOR EXCLUSIONS

Rate 2: For patients with two or more antipsychotic prescriptions ordered, exclude patients who have a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the Index Prescription Start Date (IPSD) for antipsychotics.

For patients with two or more benzodiazepine prescriptions ordered, exclude patients who have a diagnosis of seizure disorders, rapid eye movement sleep behavior disorder, benzodiazepine withdrawal, ethanol withdrawal, or severe generalized anxiety disorder on or between January 1 of the year prior to the measurement period and the IPSD for benzodiazepines.

– DENOMINATOR EXCLUSIONS

• Exclude patients who are in hospice care for any part of the measurement period.
• Exclude patients receiving palliative care during the measurement period.

For Denominator:

Include patients aged 65 and older at the start of the measurement period with a qualifying encounter during the measurement period. To record an encounter, navigate to Patient > Provider Note > eSuperbill. Under the ‘Procedure – CPTs’ heading, enter the encounter code.

For Numerator 1:

Include patients fulfilling one of the following criteria:

• Two anti-infective ordered for 90 or more days during the measurement period. The two medications should be ordered 1 day or more apart. To order a medication, use the workflow Patient > Provider Note > Prescription. Click ‘Add’ and search for the prescription. Enter the prescription details and click ‘Prescribe’.

• Two non-benzodiazepine hypnotics ordered for 90 or more days during the measurement period. The two medications should be ordered 1 day or more apart. To order a medication, use the workflow Patient > Provider Note > Prescription.
• Same high risk medications ordered on different days during the measurement period. The two medications should be ordered 1 day or more apart and should have the same code. To order a medication, use the workflow Patient > Provider Note > Prescription. Click ‘Add’ and search for the prescription. Enter the prescription details and click ‘Prescribe’.

For Numerator 2:

Include patients satisfying any of the following conditions:

• Patients with more than one ‘Antipsychotic’ medication ordered during the measurement period. The two medications should be ordered 1 day or more apart. To order a medication, use the workflow Patient > Provider Note > Prescription.
• Patients with more than one ‘Benzodiazepine’ medication ordered during the measurement period. The two medications should be ordered 1 day or more apart. To order a medication, use the workflow Patient > Provider Note > Prescription.

For Numerator 3:

Include patients:

• Fulfilling the criteria for Numerator 2 and not satisfying any of the conditions for Numerator Exclusions.
• Fulfilling the criteria for Numerator 1 and not satisfying any of the conditions for Numerator 2.

For Numerator 2 Exclusions: 

Exclude patients satisfying any of the following criteria from numerator 2:

• Patients with ‘More than One Antipsychotic’ ordered without ‘More than One Benzodiazepine’ ordered during the measurement period. Additionally, the patient should have one of the antipsychotic treated diagnosis such that the diagnosis prevalence period overlaps the interval, [start of ‘Measurement Period’ – 1 year, ‘Antipsychotic Index Prescription Start Date’].
• To add a diagnosis, use the workflow, Patient < Provider Note < Clinical < Diagnosis. Search for a diagnosis, enter the diagnosis details, and click ‘Save’. Then click ‘Accept’ and the diagnosis is added to the provider note.

• Patients with ‘More than One Benzodiazepine’ ordered without ‘More than One Antipsychotic’ ordered during the measurement period. Additionally, the patient should have one of the benzodiazepine treated diagnosis such that the diagnosis prevalence period overlaps the interval, [start of ‘Measurement Period’ – 1 year, ‘Benzodiazepine Index Prescription Start Date’].
• Patients with ‘More than One Antipsychotic’ ordered and ‘More than One Benzodiazepine’ ordered during the measurement period. The patient should have one of the antipsychotic treated diagnosis such that the diagnosis prevalence period overlaps the interval, [start of ‘Measurement Period’ – 1 year, ‘Antipsychotic Index Prescription Start Date’]. Additionally, the patient should have one of the benzodiazepine treated diagnosis such that the diagnosis prevalence period overlaps the interval, [start of ‘Measurement Period’ – 1 year, ‘Benzodiazepine Index Prescription Start Date’].

Note: Index prescription start date: The start date of the earliest prescription ordered for a high-risk medication during the measurement period.

For Denominator Exclusions:

Exclude patients satisfying any of the following criteria:

• Patients who are in hospice care during the measurement year are included in denominator exclusion. To document that patient is receiving hospice care outside of a hospital or long term care facility, navigate to Patient > Clinical > Evaluations. Click ‘+ Add’ and search for an intervention. Select ‘Order’ or ‘Performed’ from the ‘Status’ dropdown, then click ‘Sign’ or ‘Save’. Use the below mentioned codes to order or perform an intervention:
  • 385763009: Hospice Care (Regime/Therapy)
  • 385765002: Hospice Care Management (Procedure)

To document an encounter inpatient, navigate to Patient > Clinical > Evaluations

• Patients receiving palliative care during the measurement period.
  • To record the ‘Palliative Care Encounter’ performed, use the workflow Patient > Provider Note > eSuperbill.
  • To record the ‘Palliative Care Intervention’ performed, use the workflow Patient > Clinical > Evaluations.
  • To record the ‘Functional Assessment of Chronic Illness Therapy’ assessment performed, navigate to Patient > Clinical > Evaluations.