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Stage 1 Core CQMs

Additional CQMs Alternate Core CQMs CQM Intro


Every eligible professional (EP) must attest to the three core clinical quality measures (CQMs). CQMs should be reported exactly as generated by certified EHR technology. Eligible professionals should use the electronic specifications linked for each of the core CQMs below, along with the TennCare notes on the measure, to

  • understand what the CQMs indicate so that their calculation can inform clinical workflow and practice
  • ensure that the appropriate CQMs are being reported in the attestation portal: note the differences between 0028a and 0028b, or NQF 0421 population criteria 1 or 2
  • affirm that zeroes in the denominator indicate that the patient population was not seen by the EP during the EHR reporting period

 

NQF 0013
Hypertension: Blood Pressure Management
Percentage of patient visits for patients aged 18 years and older with a diagnosis of hypertension who have been seen for at least 2 office visits, with blood pressure (BP) recorded.
NQF 0013 Notes: As the patient population captures those 18 and older, pediatricians and nurse practitioners with a pediatric scope may have a denominator of zero for this measure, requiring an attestation to an alternate core CQM in addition to attesting to zeroes for this measure’s numerator and denominator. Also, given the criteria that the patient has two encounters and a diagnosis of hypertension, providers who serve an adult patient population will likely not have all of their unique patients reflected in the denominator of this measure.
NQF 0028
Preventive Care and Screening Measure Pair:

a) Tobacco Use Assessment

b) Tobacco Cessation Intervention
a) Tobacco Use Assessment
Percentage of patients aged 18 years and older who have been seen for at least two office visits who were queried about tobacco use one or more times within 24 months.

b) Tobacco Cessation Intervention
Percentage of patients aged 18 years and older identified as tobacco users within the past 24 months and have been seen for at least 2 office visits, who received cessation intervention.
NQF 0028 Notes: This clinical quality measure has two parts, NQF 0028a and b. Both must be reported exactly as generated by the certified EHR technology in order to attest to this measure. The denominator of NQF 0028a captures all patients 18 and older with one preventive encounter or two counts of other encounters, including psychiatric and psychological, while the numerator reflects those who have an answer recorded for whether they use tobacco. The denominator of 0028b is then a subset of 0028a, those who answered yes to being a tobacco user. The numerator of 0028b reflects cessation counseling or medication. The denominator of 0028b, then, should be less than the denominator of 0028a unless every patient in 0028a was queried about tobacco use and was indeed a tobacco user.

As the patient population captures those 18 and older, pediatricians and nurse practitioners with a pediatric scope may have a denominator of zero for this measure, requiring an attestation to an alternate core CQM in addition to attesting to zeroes for this measure’s numerator and denominator. Also, given the criteria that the patient has two encounters or one preventive encounter, even providers who serve an adult patient population will likely not have all of their unique patients reflected in the denominator of this measure.
NQF 0421
Adult Weight Screening and Follow-Up
Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow-up plan is documented.
NQF 0421 Notes: This measure has two parts, a numerator and denominator for population criteria 1 and population criteria 2.  According to the specification, population criteria 1 captures patients 65 and older who meet the specified criteria, while population criteria 2 captures the 18-64 year olds. The denominator for each age range includes all patients with one outpatient encounter, so the number of unique patients seen during the EHR reporting period could be equal to the sum of the denominators for these measures if an adult population is seen by the EP. The numerators capture activities performed given particular ranges of BMIs. The exclusions capture patients not included in the denominator because calculating their BMI would have been inappropriate or a physical exam was not performed.

As the patient population captures those 18 and older, pediatricians and nurse practitioners with a pediatric scope may have a denominator of zero for this measure, requiring an attestation to an alternate core CQM in addition to attesting to zeroes for this measure’s numerator and denominator.