Quality ID #238 | PracticeSuite

Quality ID #238 (NQF 0022): Use of High-Risk Medications in Older Adults

— National Quality Strategy Domain: Patient Safety

— Meaningful Measure Area: Medication Management

2022 COLLECTION TYPE:

MIPS CLINICAL QUALITY MEASURES (CQMS)

MEASURE TYPE:

Process – High Priority

DESCRIPTION:

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class

INSTRUCTIONS:

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

The measure reflects potentially inappropriate medication use in older adults, both for medications where any use is inappropriate and for medications where use under all but specific indications is potentially inappropriate.

This measure will be calculated with 2 performance rates:

Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class.
Percentage of patients 65 years of age and older who were ordered at least two high-risk medications from the same drug class, except for appropriate diagnoses.

For accountability reporting in the CMS MIPS program, the rate for submission criteria 1 is used for performance.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

SUBMISSION CRITERIA 1: PERCENTAGE OF PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS

DENOMINATOR (SUBMISSION CRITERIA 1):

Patients 65 years and older who had a visit during the measurement period

Denominator Criteria:

Patients aged ≥ 65 years on date of encounter

AND

Patient encounter during performance period (CPT or HCPCS): 92002, 92004, 92012, 92014, 99202, 99203, 99204, 99205,99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99385*, 99386*, 99387*, 99395*, 99396*, 99397*, G0438, G0439

AND NOT

DENOMINATOR EXCLUSIONS:

Patients who use hospice services any time during the measurement period: G9741

Patients receiving palliative care during the measurement period: G0034

NUMERATOR (SUBMISSION CRITERIA 1):

Patients ordered at least two high-risk medications from the same drug class during the measurement year.

Definitions:

The intent of the measure is to assess if the eligible clinician ordered high-risk medication(s). The intent of the numerator is to assess if the patient has either been ordered:

- At least two high-risk medications from the same drug class (grouped by row) in Table 1 ondifferent dates of service, or
- At least two high-risk medications from the same drug class (grouped by row) in Table 2 ondifferent dates of service, where the sum of days supply exceeds 90 days

If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the submitting provider also ordered a high-risk medication for them from the same drug class.

Cumulative Medication Duration – an individual’s total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed.

To determine the “cumulative medication duration”, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions.

For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was ordered again for 60 days with 1 refill for 60 days. The “cumulative medication duration” is (30 x 3) + (60 x 2) = 210 days over the 10 month period.

Table 1 – High-Risk Medications at any dose or duration

Description	Prescription
Anticholinergics, first-generation antihistamines	Brompheniramine Doxylamine Carbinoxamine Hydroxyzine Chlorpheniramine Meclizine Clemastine Promethazine Cyproheptadine Pyrilamine Dexbrompheniramine Triprolidine Dexchlorpheniramine Dimenhydrinate Diphenhydramine (oral)
Anticholinergics, anti-Parkinson agents	Benztropine (oral) Trihexyphenidyl
Antispasmodics	Atropine (exclude ophthalmic) Hyoscyamine Belladonna alkaloids Methscopolamine Chlordiazepoxide-clidinium Propantheline Dicyclomide Scopolamine

Description	Prescription
Antithrombotics	Dipyridamole, oral short- acting
Cardiovascular, alpha agonists, central	Methyldopa Guanfacine
Cardiovascular, other	Disopyramide Nifedipine, immediate release
Central nervous system, antidepressants	Amitriptyline Imipramine Clomipramine Trimipramine Amoxapine Nortriptyline Desipramine Paroxetine Protriptyline
Central nervous system, barbiturates	Amobarbital Pentobarbital Butabarbital Phenobarbital Butalbital Secobarbital
Central nervous system, vasodilators	Ergot mesylates Isoxsuprine
Central nervous system, other	Meprobamate
Endocrine system, estrogens with or without progestins; include only oral and topical patch products	Conjugated estrogen Estradiol Estropipate Esterified estrogen
Endocrine system, sulfonylureas, long-duration	Chlorpropamide Glyburide Glimepiride
Endocrine system, other	Desiccated thyroid Megestrol
Nonbenzodiazepine hypnotics	Eszopiclon Zolpidem Zaleplon
Pain medications, skeletal muscle relaxants	Carisoprodol Metaxalone Methocarbamol Chlorzoxazone Orphenadrine Cyclobenzaprine
Pain medications, other	Indomethacin Meperidine Ketorolac, includes parenteral

*The registry version of the measure specifications only indicates the classes of drugs that are considered high-risk and do not include the specific coding of RxNorm. However, this measure aligns with the eCQM measure (CMS 156) and providers may review the RxNorm codes in the applicable eCQM value sets for submission.

Table 2 – High-Risk Medications With Days Supply Criteria

Description

Prescription

Days Supply Criteria

Anti-Infectives, other

Nitrofurantoin Nitrofurantoin

Nitrofurantoin macrocrystals-

macrocrystals monohydrate

>90 days

Numerator Instructions:

INVERSE MEASURE – A lower calculated performance rate for this measure indicates better clinical care or control. The “Performance Not Met” numerator option for this measure is the representation of the better clinical quality or control. Submitting that numerator option will produce a performance rate that trends closer to 0%, as quality increases. For inverse measures a rate of 100% means all of the denominator eligible patients did not receive the appropriate care or were not in proper control.

A high-risk medication is identified by either of the following:

- A prescription for medications classified as high risk at any dose and for any duration listed in Table 1
- Prescriptions for medications classified as high risk at any dose with greater than a 90 day cumulative medication duration listed in Table 2

Numerator Options:

Performance Met: At least two orders for high-risk medications from the same drug class (G9367)

Performance Not Met: At least two orders for high-risk medications from the same drug class not ordered (G9368)

SUBMISSION CRITERIA 2: PERCENTAGE OF PATIENTS 65 YEARS OF AGE AND OLDER WHO WERE ORDERED AT LEAST TWO HIGH-RISK MEDICATIONS FROM THE SAME DRUG CLASS, EXCEPT FOR APPROPRIATE DIAGNOSES

DENOMINATOR (SUBMISSION CRITERIA 2):

Patients 65 years and older who had a visit during the measurement period

Denominator Criteria:

Patients aged ≥ 65 years on date of encounter

AND

AND NOT

DENOMINATOR EXCLUSIONS:

Patients who use hospice services any time during the measurement period: G9741

Patients receiving palliative care during the measurement period: G0034

NUMERATOR (SUBMISSION CRITERIA 2):

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

Definitions:

The intent of the numerator is to assess if the patient has been ordered at least two high-risk medications from the same drug class (grouped by row) in Table 3 on different dates or service. The intent of the measure is to assess if the submitting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the submitting provider also ordered a high-risk medication for them from the same drug class.

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

Table 3 – High-Risk Medications

Description

Prescription

Antipsychotics, first (conventional) and second (atypical) generation

Aripiprazole Molindone

Asenapine Olanzapine

Brexpiprazole Paliperidone

Cariprazine Perphenazine

Chlorpromazine Pimavanserin

Clozapine Pimozide

Fluphenazine Quetiapine

Haloperidol Risperidone

Iloperidone Thioridazine

Loxapine Thiothixene

Lurasidone Trifluoperazine

Ziprasidone

Benzodiazepines, long, short and intermediate acting

Alprazolam Lorazepam

Chlordiazepoxide Midazolam

Clonazepam Oxazepam

Clorazepate Quazepam

Diazepam Temazepam

Estazolam Triazolam

Flurazepam

Numerator Instructions:

A high-risk medication is identified by:

- A prescription for medications classified as high risk at any dose and for any duration listed in Table 3

Numerator Options:

Performance Met: At least two orders for high-risk medications from the same drug class (G9367)

Performance Not Met: At least two orders for high-risk medications from the same drug class not ordered (G9368)

Performance Not Met: Two or more antipsychotic prescriptions ordered for patients who had a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder on or between January 1 of the year prior to the measurement period and the Index Prescription Start Date (IPSD) for antipsychotics (G0032)

Performance Not Met: Two or more benzodiazepine prescriptions ordered for patients who had 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 IPSD for benzodiazepines (G0033)