CMS153v12 – Chlamydia Screening in Women

Chlamydia Screening in Women	CMS153v12	Percentage of women 16-24 years of age who were identified as sexually active at any time during the measurement period and who had at least one test for chlamydia during the measurement period
– DENOMINATOR Women 16 to 24 years of age by the end of the measurement period who are sexually active and who had a visit in the measurement period. Identifying women as sexually active can be done through: Assessments Diagnoses Active/Ordered Contraceptive Medication  Laboratory Tests Diagnostic Studies Procedures A qualifying visit in this case can include any of the following: Office Visit Preventive Care Services, Initial Office Visit, 0 to 17 Preventive Care, Established Office Visit, 0 to 17 Preventive Care Services Established Office Visit, 18 and Up Preventive Care Services Initial Office Visit, 18 and Up Telephone Visits Online Assessments Home Healthcare Services – NUMERATOR Women with at least one chlamydia test during the measurement period – DENOMINATOR EXCLUSIONS Women who are only eligible for the initial population due to a pregnancy test and who had an order for an x-ray or for a specified medication on the date of the pregnancy test or the six days after the pregnancy test. Note: The lab test can either be paired with a diagnostic study or with an order of Isotretinoin medication. Patients who are in hospice care for any part of the measurement period.

APPLICATION WORKFLOW

For Denominator:

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

• Sexual activity can be documented through the following methods:
  • To document:
    • an assessment
    • diagnostic study

navigate to Patient > Provider Note > Evaluations. Click ‘Add’ and search for an assessment or diagnostic study. From the status drop-down select its relevant status and once done, click ‘Save & Accept’ or ‘Sign & Accept’.

• Sexual activity can also be recorded via the workflow Patient > Provider Note > History > Social > Sexual. Select ‘Active’ from the ‘Sexually Active’ dropdown. Then click ‘Accept’.

• To document a diagnosis for sexual activity, use the workflow Patient > Provider Note > Diagnoses, and click ‘Add’. Search for the relevant diagnosis and add the diagnosis details. Then click ‘Save’.

• To place an order for a lab test to identify sexual activity, navigate to Patient > Provider Note > Orders > Lab and click ‘Add’. Select a laboratory here and then proceed to search for the relevant lab test. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

• Procedures identifying sexual activity can be documented through Patient > Provider Note > Orders > Procedures. Here, click ‘Add’ and search for the relevant procedure. Fill out any details needed and once done, click ‘Save & Accept’ or ‘Sign & Accept’.

• Contraceptive medication can be ordered through Patient > Provider Note > Prescription while an active contraceptive medication can be documented via Patient > Provider Note > Medications.

For Numerator:

• To order a chlamydia test, use the workflow Patient > Provider Note > Orders > Lab and click ‘Add’.  Select a laboratory and from the drop-down menu and then search for the relevant lab test. Once done, click ‘Save & Accept’ or ‘Sign & Accept’.

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.
• To place an order for laboratory pregnancy test, use the workflow Patient > Provider Note > Orders > Lab.

Note: The pregnancy test should be ordered during the measurement period.

• An ‘X-Ray Study (all inclusive)’ diagnostic study can be ordered via Patient > Provider Note > Orders > Radiology.

Note: ‘X-Ray Study (all inclusive)’ diagnostic study should be ordered 7 days or less after day of ‘Pregnancy Test’.

• Isotretinoin can be prescribed using the workflow Patient > Provider Note > Prescription. Here, click ‘Add’ and search for the relevant medication. Fill out any details as needed and once done, click ‘Prescribe’.

Along with the above-mentioned conditions, the following must also be fulfilled in order for females to qualify for denominator exclusions:

1. Female patients with no record of diagnoses identifying sexual activity.
2. Female patients with no record of active contraceptive medications.
3. Female patients with no record of laboratory tests identifying sexual activity but not pregnancy.
4. Female patients with no record of procedures identifying sexual activity.
5. Female patients with no record of assessments identifying sexual activity.
6. Female patients with no record of ordered contraceptive medications.
7. Female patients with no record of diagnostic studies identifying sexual activity.