APMA News - March/April 2020 - 16

Do You Know Your Quality Measures?

By James R. Christina, DPM; Jeffrey D. Lehrman, DPM; and Dyane E. Tower, DPM, MPH, MS

t is extremely important that you understand your selected
quality measures inside and out. Each measure you select
has its own measure specification document that tells you
everything you need to know about the measure and how to
report your performance. You should know the details within
the measure specification document very well because the
measure specifications tell you who is eligible for the measure
(the denominator), what constitutes performance of the measure, how to report whether you performed (or did not perform) the measure, required documentation, and the rationale
behind the measure.
In the November/December 2019 issue of APMA News (page
60), we discussed the different collection types of quality measures (claims, MIPS CQMs [registry measures], and eCQMs
[EHR measures]), and in this issue, we walk you through the
measure specification of MIPS CQM (registry measure) #126:
Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral
Neuropathy-Neurological Evaluation.
The MEASURE SPECIFICATION DOCUMENT 1 .
The gray box at the top of the page (see figure on page 17)
includes the identification, title, and domain of the measure.
The YEAR 2 and COLLECTION TYPE 3 are next. Be
sure you are looking at the document that has the current MIPS
performance year (PY) and that the collection type is the one
you are looking to report. Measure #126 is only available as
a MIPS CQM, so there is only one measure specification document, but, for example, Measure #226: Preventive Care and
Screening: Tobacco Use: Screening and Cessation Intervention
can be reported via claims, MIPS CQM, or eCQM, and each
collection type has its own measure specification document.

and older with a diagnosis of diabetes mellitus who had a
neurological examination of their lower extremities within 12
months." The description gives you an initial idea of what the
numerator and denominator of the measure will look like.
The INSTRUCTIONS 6 for the measure give you specific information on the measure and how often it should be
reported for eligible patients (i.e., patients who meet the denominator criteria). For Measure #126, you are to submit the
measure a minimum of once per performance period. In contrast, Measure #130: Documentation of Current Medications
in the Medical Record (a high-priority measure of interest to
DPMs) is to be submitted at each denominator-eligible visit
during the performance period.
The DENOMINATOR 7 tells you which patients are eligible for the measure. Report your performance for patients
who meet the denominator criteria. In the case of Measure
#126, a patient must be 18 years and older, and have a diagnosis of diabetes (as indicated by an ICD-10 code listed in the
measure specifications), and have a patient encounter during
the performance period (as indicated by one of the CPT codes
listed in the measure specifications). The appropriate ICD-10
and CPT codes must be present on the claim for the encounter
for the patient to be eligible for the measure. The encounter
cannot have a telehealth modifier; if it does, the patient is ineligible for the measure during that encounter. Furthermore, if
the patient meets the criteria for a denominator exclusion for
a measure, that patient is removed from the denominator.

Next, the MEASURE TYPE 4 indicates whether the measure is considered a process, outcome, or high-priority measure.
For the Quality category, if you report six measures, one of
your quality measures must be an outcome measure, or, if you
do not think there is an outcome measure to report, you must
have at least one high-priority measure. Check out the list of
recommended quality measures by collection type at www.
apma.org/mips2020 to make sure you meet this requirement
with your selected measures.

The purpose of Measure #126 is to identify whether or not
diabetic patients at risk received a neurological exam. The
NUMERATOR 8 describes the examination to be performed,
and you can report that you performed and documented the
exam (Performance Met) or did not (Performance Not Met).
Depending on which numerator option is applicable, report
the corresponding g-code. If you performed and documented
a neurological exam on an eligible patient (a patient aged 18
years or older, with an ICD-10 code for diabetes on the list,
and with an eligible CPT encounter on the list), report G8404.
If you did not perform the neurological exam on an eligible patient, report G8405.

The DESCRIPTION 5 of the measure tells you exactly
what the measure is looking for. In the case of Measure #126,
we are looking for the "Percentage of patients aged 18 years

The RATIONALE 9 and CINICAL RECOMMENDATION STATEMENTS 10 provide additional support on the
importance of the quality action of the measure.

16 APMA News March/April 2020

http://www.apma.org/mips2020 http://www.apma.org/mips2020

APMA News - March/April 2020

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