CMS156v11 – 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.

NUMERATOR 3: 

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

This means either consider “Numerator 2” without the “Numerator Exclusion”, or consider “Numerator 1” without “Numerator 2”.

– NUMERATOR EXCLUSIONS

For Numerator 1: None

For Numerator 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 IPSD for antipsychotics.
• For patients with two or more benzodiazepine prescriptions ordered, exclude patients who have a diagnosis of seizure disorders, rapid eye movement (REM) 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.

Index Prescription Start Date (IPSD). The start date of the earliest prescription ordered for a high-risk medication during the measurement period.

For Numerator 3: None

– 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/visit, navigate to Patient > Provider Notes > Create Superbill. Under the ‘Procedure-CPTs’ heading, enter the relevant encounter code.

For Numerators 1,2 &3:

To record medications being ordered for a patient, navigate to Patient > Provider Notes > Prescriptions. Click ‘Add’ and search for the relevant medication. Once done, click ‘Prescribe’.

For Denominator Exclusions:

• To document a patient receiving hospice care, navigate to Patient > Provider Notes > Evaluations. Hospice Care can also be recorded by the workflow Patient > Provider Notes > Create Superbill. Under the ‘Procedure-CPTs’ heading, add the relevant hospice care code.

• Documentation of a palliative assessment can be done via Patient > Provider Notes > Evaluations or through Patient > Provider Notes > Assessments.

• To record a palliative encounter, navigate to Patient > Provider Notes > Create Superbill or use the workflow Patient > Provider Notes > Diagnoses. Here, document a diagnosis for ‘Encounter for palliative care’.

• The documentation of a palliative intervention can be done through Patient > Provider Notes > Evaluations. Here, click ‘Add’ and select the relevant status from the drop down. Once done, click ‘Save’.

For Numerator Exclusions:

• To record medications for antipsychotic and benzodiazepine, navigate to Patient > Provider Notes > Prescriptions. Click ‘Add’ and search for the relevant medication. Once done, click ‘Prescribe’.

• Documentation of
  • Schizophrenia
  • Bipolar Disorder
  • Seizure Disorder
  • REM Sleep Behavior Disorder
  • Benzodiazepine Withdrawal
  • Alcohol Withdrawal
  • Generalized Anxiety Disorder

can be done via Patient > Provider Notes > Diagnoses. Click ‘Add’ and search for the relevant diagnosis. Fill out the details and once done, click ‘Save’.