Product Lines:
Advantage MD, Dual Eligible Special Needs Plans (D-SNP).

Eligible Population:
Members 66 years of age and older as of December 31 of the measurement year.

Description:
The percentage of adults 66 years and older who had each of the following during the measurement year:

• Medication review.  Provider type must be a prescribing practitioner or clinical pharmacist:
• Functional status assessment.*
• Pain assessment.*

NOTE:  Above can be documented through Admin Data or Medical record review:

• *The Functional Status Assessment and Pain Assessment indicators do not require a specific setting. Therefore, services rendered during a telephone visit, e-visit or virtual check-in meet criteria

Continuous Enrollment:

• The measurement year.

Best Practice and Measure Tips

Medication review:

Either of the following meets criteria:

• Both of the following during the same visit with the appropriate provider:  
  • At least one medication review (Medication Review Value Set).
  • The presence of a medication list in the medical record (Medication List Value Set). or
  • Transitional care management services during the measurement year.
• A medication list, signed and dated during the measurement year meets criteria:  The practitioner’s signature is considered evidence that the medications were reviewed. 
• Review and List of the member’s medications in the medical record: May include medication names only or may include medication names, dosages and frequency, over-the-counter (OTC) medications and herbal or supplemental therapies. 
• A medication review performed without the member present meets criteria.

Functional status assessment
A complete functional status assessment must include one of the following:

• Notation that Activities of Daily Living (ADL) were assessed or
• Notation that at least five of the following were assessed:
  • Bathing, dressing, eating, transferring [e.g., getting in and out of chairs], using toilet, walking.
• Notation that Instrumental Activities of Daily Living (IADL) were assessed or
• Notation that at least four of the following were assessed:
  • Shopping for groceries, driving or using public transportation, using the telephone, cooking or meal preparation, housework, home repair, laundry, taking medications, handling finances. •    
• Documentation in the medical record must include evidence of a complete functional status assessment and the date when it was performed.
• A functional status assessment limited to an acute or single condition, event or body system (e.g., lower back, leg) does not meet criteria for a comprehensive functional status assessment.
• The components of the functional status assessment numerator may take place during separate visits within the measurement year.
• Do not include comprehensive functional status assessments performed in an acute inpatient setting.
• A set of structured questions that elicit member information may be helpful.   May include person-reported outcome measures, screening or assessment tools or standardized questionnaires. 
• Result of assessment using a standardized functional status assessment tool, not limited to:
  • SF-36®.
  • Assessment of Living Skills and Resources (ALSAR).
  • Barthel ADL Index Physical Self-Maintenance (ADLS) Scale.
  • Bayer ADL (B-ADL) Scale.
  • Barthel Index.
  • Edmonton Frail Scale.
  • Extended ADL (EADL) Scale.
  • Groningen Frailty Index.
  • Independent Living Scale (ILS).
  • Katz Index of Independence in ADL.
  • Kenny Self-Care Evaluation.
  • Klein-Bell ADL Scale.
  • Kohlman Evaluation of Living Skills (KELS).
  • Lawton & Brody’s IADL scales.
  • Patient Reported Outcome Measurement Information System (PROMIS) Global or Physical Function Scales.

Pain Assessment:

Documentation in the medical record must include evidence of a pain assessment and the date when it was performed.

• A medication review performed without the member present meets criteria.

Notations for a pain assessment must include one of the following:

• Documentation that the patient was assessed for pain (which may include positive or negative findings for pain)
• Result of assessment using a standardized pain assessment tool, not limited to:
  • Numeric rating scales (verbal or written).
  • Face, Legs, Activity, Cry Consolability (FLACC) scale.
  • Verbal descriptor scales (5–7 Word Scales, Present Pain Inventory).
  • Pain Thermometer.
  • Pictorial Pain Scales (Faces Pain Scale, Wong-Baker Pain Scale).
  • Visual analogue scale.
  • Brief Pain Inventory.
  • Chronic Pain Grade.
  • PROMIS Pain Intensity Scale.
  • Pain Assessment in Advanced Dementia (PAINAD) Scale.

Not Acceptable for Pain Assessment: 

• Do not include pain assessments performed in an acute inpatient setting.
• Notation alone of a pain management plan does not meet criteria.
• Notation alone of a pain treatment plan does not meet criteria.
• Notation alone of screening for chest pain or documentation alone of chest pain does not meet criteria.

Measure Exclusions

Required Exclusion: 

• Members in hospice or using hospice services anytime during the measurement year.
• Exclude services provided in an acute inpatient setting.
• Members who died any time during the measurement year.

Measure Codes

• Medication review:  
  • CPT: 90863, 99483, 99605, 99606  
  • CPT II: 1160F
• Medication List:
  • CPT II: 1159F
  • HCPCS: G8427
• Transitional Care Management Services 
  • CPT: 99495, 99496
• Functional status assessment    
  • CPT: 99483
  • CPT II: 1170F
  • HCPCS: G0438, G0439
• Pain assessment
  • CPT II: 1125F, 1126F