eCQM: Falls: Screening for Future Fall Risk (CMS 139v5)

eCQM:

Falls: Screening for Future Fall Risk

CMS ID:

CMS 139v5

Measure Type:

Process

MIPS High Priority Measure:

Yes

Quality ID:

318

Eligible for Quality Programs:

  • Merit-Based Incentive Payment System (MIPS)
  • Medicaid EHR Incentive Program (Meaningful Use)
  • Comprehensive Primary Care Plus (CPC+)

Performance Benchmark for MIPS:

98.50%

Description:

Percentage of patients 65 years of age and older who were screened for future fall risk at least once during the measurement period.

  • Numerator: Patients who were screened for future fall risk at least once within the measurement period.

  • Denominator: Patients aged 65 years and older with an eligible visit (defined in Table 1) during the measurement period.

    • Denominator Exclusions: None 

    • Denominator Exceptions:Documentation of medical reason(s) for not screening for fall risk (e.g., patient is not ambulatory).

Table 1. Eligible Visits for CMS 139v5

Encounter Types

  • Office Visit
  • Home Visit
  • Nurse Visit
  • Nursing Home Visit

eCQM Patient Reports

eCQM Patient Reports can help you identify patient care gaps and improve the performance of your quality measures. Click on the blue result numbers in the eCQM Dashboard to see the patient report for this measure.

The eCQM Patient Reports list the individual patients included in the measure’s population, which measure cohorts the patient is in, and contact information for the patient to streamline any downstream communication that may be needed to fulfill the measure requirements. You can choose to print the patient list for a measure or export it as a CSV.

The measure cohorts included in the eCQM Patient Report for CMS 139v5 Falls: Screening for Future Fall Risk are:

  • Initial patient population
  • Denominator
  • Numerator
  • Exception

Practice Fusion Suggested Workflow
Practice Fusion suggests the following workflow to help ensure that you are able to meet the requirements of this measure within the Practice Fusion EHR.

  1. Record the performed Falls Risk Assessment in the patient encounter using the suggested workflow outlined below:

    1. In the Screenings/Interventions/Assessments section of the encounter, search for the appropriate fall assessment performed and select the item. Examples include:

      • Fall risk assessment (procedure) (SNOMED CT 414191008)

      • Get up and go test (procedure) (SNOMED CT 401196007)

      • Post fall assessment (procedure) (SNOMED CT 427206005)

    2. Record and save the following information in the modal window that opens:

      • Status: Performed

      • Start Date: If the assessment was performed on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the assessment

      • Note: A result is not required for the purposes of this measure

Additional Measure Information

  • This 2016 measure version has been updated from the previous 2015 version specifications, incorporating the following change:

    • Clarified the definition of screening for future fall risk.

  • If the assessment was not completed for a medical reason, you can use the workflow outlined below to document for the denominator exclusion.

    • In the Screenings/Interventions/Assessments section of the encounter, search for the appropriate fall risk assessment and select the item. See the suggested workflow above for assessment examples.

    • Record and save the following information in the modal window that opens:

      • Status: Not Performed

      • Reason: Medical contraindication, Procedure contraindicated, OR Treatment not tolerated

      • Start Date: If the assessment refusal was entered on the same date of service as the encounter in which it is recorded in the Screenings/Interventions/Assessments section, a start or end date should not be entered for the refusal.

  • “Screening for Future Fall Risk” is generally defined as an assessment of whether an individual has experienced a fall or problems with gait or balance. A specific screening tool is not required for this measure, however potential screening tools include the Morse Fall Scale and the timed Get-Up-And-Go test.

  • “Fall” is generally defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.

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