How to Pass PQRS

We have less than two weeks in the deadline for Registry Reporting deadlines for 2016 Meaningful Use Stage 2 Objective 10 (February 29, 2016).  But let’s not forget the preparation required in order to successfully pass Quality Reporting for PQRS.
Below is a list of Measures specific to Wound Care: PQRS and CDR.  I’ve outlined the “how-to” for each measure.  For a complete list which includes NQS Domain, Frequency during the Reporting Period (in the eligible population), and Cross-Cutting, I’ve provided a link to the PDF here: How-to-Pass-PQRS

PQRS #1 – Hemoglobin A1c Poor Control

• How-to Pass = Record one Hgb A1c value from any provider LESS than 9%

PQRS #46 – Medication Reconciliation

• How-to Pass = Document that Medication Reconciliation was done each time there is a hospital discharge

PQRS #47 – Care Plan

• How-to Pass =Advanced Care Plan was discussed and documented.

PQRS #128 – Body Mass Index (BMI) Screening and Follow-Up Plan

• How-to Pass = Record a BMI at least once. If BMI is MORE than 30 or LESS than 23, document nutritional follow-up plan.

PQRS #130 – Documentation of Current Medications in the Medical Record

• How-to Pass = Document current medications at each visit.

PQRS #163 – Diabetic Foot Exam

• How-to Pass = Document all needed elements of foot exam one time.

PQRS #226 – Tobacco Use Screening and Cessation Intervention

• How-to Pass = Document smoking status. If a smoker, document an intervention plan.

PQRS #236 – Controlling High Blood Pressure

• How-to Pass = Document one BP value less than 140/90.

PQRS #431 – Screening for Unhealthy Alcohol Use

• How-to Pass = Perform an alcohol screen.

CDR #1 – Diabetic Foot Ulcer Offloading

• How-to Pass = Document appropriate offloading of a DFU at each visit.

CDR #5 – Venous Ulcer Compression

• How-to Pass = Document appropriate compression of a VLU at each visit.

CDR #8 – Appropriate Use of HBOT for a Diabetic Foot Ulcer

• How-to Pass = Prior to initiating a course of HBOT for a DFU, document that ulcer is a Wagner 3, Vascular screening completed, offloading documented at each visit, and Hemoglobin A1c recorded (composite of PQRS #1, CDR #1, and CDR #10)

CDR #9 – Appropriate Use of Cellular Products for Diabetic Foot Ulcers and Venous Leg Ulcers

• How-to Pass = Prior to applying a cellular product, document that wound has been present 30 days, document Vascular screening completed, off-loading documented for DFUs at each visit, compression documented for VLU at each visit (composite of PQRS #1, CDR #1, and CDR #10)

CDR #10 Vascular Assessment of Patients with Leg Ulcers

• How-to Pass = Document vascular assessment with any of the following: palpable pulses, ABI, TCOM, or vascular study.

CDR #20 Nutritional Screening of Patients with Wounds

• How-to Pass = Document Nutritional Screening with Nestle MNA on Assessment, and MNA directed intervention.

CDR #13 Vital Signs Prior to HBOT

• How-to Pass = Document vital signs prior to each hyperbaric treatment

CDR #14 Finger Stick Blood Glucose Prior to HBOT

• How-to Pass = Document finger stick blood sugar prior to HBOT in all patients with an ICD-10 diagnoses of diabetes.

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Now go and Do the Right Thing™
Caroline Fife, MD
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The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.