CMS156v12 – Use of High-Risk Medications in Older Adults

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

A qualifying visit in this case can include any of the following:

• Office Visit
• Ophthalmologic services
• Preventive Care Services Established Office Visit, 18 and Up
• Discharge Services Nursing Facility
• Nursing Facility Visit
• Care Services in Long Term Residential Facility
• Preventive Care Services Initial Office Visit, 18 and Up
• Annual Wellness Visit
• Home Healthcare Services
• Telephone Visits
• Online Assessments
• Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified healthcare professional. Usually, the presenting problem(s) are minimal.

– NUMERATOR 

NUMERATOR 1:

Patients with at least two orders of high-risk medications from the same drug class on different days. A high-risk medication is identified by any one of the following:

1. At least two orders of high-risk medications from the same drug class.

The following medications classify as high risk at any dose and for any duration and thus are considered for category 1a:

• Benztropine
• Trihexyphenidyl
• Hydroxyzine
• Dimenhydrinate
• Brompheniramine
• Clemastine
• Diphenhydramine
• Dexbrompheniramine
• Meclizine
• Doxylamine
• Triprolidine
• Cyproheptadine
• Promethazine
• Pyrilamine
• Chlorpheniramine
• Dexchlorpheniramine
• Carbinoxamine
• Antipsychotics
• Dicyclomine
• Chlordiazepoxide / Clidinium
• Belladonna
• Hyoscyamine
• Scopolamine
• Methscopolamine
• Atropine
• Propantheline
• Dipyridamole
• Benzodiazepine
• Methyldopa
• Guanfacine
• Disopyramide
• Nifedipine
• Imipramine
• Nortriptyline
• Amitriptyline Hydrochloride
• Amoxapine
• Paroxetine
• Protriptyline
• Trimipramine
• Clomipramine
• Desipramine
• Butabarbital
• Butalbital
• Secobarbital
• Pentobarbital
• Phenobarbital
• Amobarbital
• Meprobamate
• Isoxsuprine
• Ergoloid Mesylates
• Estropipate
• Esterified Estrogens
• Conjugated Estrogens
• Estradiol
• Desiccated Thyroid
• Megestrol
• Glyburide
• Chlorpropamide
• Glimepiride
• Nonbenzodiazepine hypnotics
• Ketorolac Tromethamine
• Indomethacin
• Meperidine
• Chlorzoxazone
• Methocarbamol
• Carisoprodol
• Metaxalone
• Cyclobenzaprine Hydrochloride
• Orphenadrine

2. At least two orders of high-risk medications from the same drug class with summed days’ supply greater than 90 days. This medication can include prescriptions of:

• Anti-infectives, other

owing to the fact that anti-infectives are classified as high risk at any dose with greater than a 90-day supply. Thus, it is considered for category 1b.

3. At least two orders of high-risk medications from the same drug class each exceeding average daily dose criteria.

Any of the following medications are classified as high risk when they exceed the specified average daily dose, and thus are considered for category 1c:

• Reserpine with average daily dose > 0.1 mg/d
• Digoxin with average daily dose > 0.125 mg/d
• Doxepin with average daily dose > 6 mg/d

Either of the three conditions a, b and c can be fulfilled in order to qualify for numerator 1.

NUMERATOR 2: 

Patients with at least two orders of high-risk medications from the same drug class (i.e., antipsychotics and benzodiazepines) on different days except for appropriate diagnoses.

1. Patients with two or more antipsychotic prescriptions ordered on different days, and who did not 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 IPSD for antipsychotics.
2. Patients with two or more benzodiazepine prescriptions ordered on different days, and who did not 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 ISPD for benzodiazepines.

NUMERATOR 3: 

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

This means either Numerator 2 is true, or Numerator 1 is true but Numerator 2 is not true.

– DENOMINATOR EXCLUSIONS

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

For Denominator:

To record an encounter, navigate to Patient > Provider Note > Create Superbill. Under the ‘Procedure-CPTs’ heading, enter the relevant encounter code.

For Numerators 1 &3:

To prescribe medication to a patient, navigate to Patient > Provider Note > Prescription. Click ‘Add’ and search for the relevant medication. Once done, click ‘Prescribe’.

For Numerator 2:

To order benzodiazepine or antipsychotics, head over to Patient > Provider Note > Prescription. Here, click ‘Add’ and search for the relevant medication, fill out the details as needed and once done, click ‘Prescribe’.

Note: It’s crucial to consider that in order to count patients in the numerator for whom antipsychotics are prescribed, they must not meet the following criteria:

• Diagnosis of Schizophrenia
• Diagnosis of Schizoaffective Disorder
• Diagnosis of Bipolar disorder

Similarly, individuals who are prescribed benzodiazepines must not meet the following criteria:

• Diagnosis of Seizure Disorders
• Diagnosis of REM behavior disorder
• Benzodiazepine Withdrawal
• Ethanol Withdrawal
• Severe Generalized Anxiety Disorder

For Denominator Exclusions:

• To document that a patient is receiving hospice care outside of a hospital or long-term care facility, navigate to Patient > Provider Note > Evaluations. Use the below mentioned codes to order or perform an intervention:
  • 385763009: Hospice Care (Regime/Therapy)
  • 385765002: Hospice Care Management (Procedure)

• To document an inpatient encounter, navigate to Patient > Provider Note > Evaluations.

• To document a hospice care assessment, follow the workflow Patient > Provider Note > Evaluations. Click ‘Add’ and search for ‘Hospice Care [Minimum Data Set]’. Then select ‘Performed’ from the ‘Status’ dropdown and ‘Yes’ from the ‘Result’ field.

• A hospice encounter can be documented through Patient > Provider Note > Evaluations or Patient > Provider Note > Create Superbill.
• For patients receiving palliative care during the measurement period:
  • To record the ‘Palliative Care Encounter’, head over to Patient > Provider Note > Create Superbill

• To record the ‘Palliative Care Intervention’, use the workflow Patient > Provider Note > Evaluations.

• To record the ‘Functional Assessment of Chronic Illness Therapy’ assessment, navigate to Patient > Provider Note > Evaluations.
• The “Encounter for palliative care” diagnosis can be recorded via Patient > Provider Note > Diagnoses.