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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