Documentation Requirements


2018 MIPS Measures for Urgent Care

MIPS Measure: #47 Advanced Care Plan

For all Medicare patients ≥65 years of age

Documentation Requirement

Document whether an advance care plan is found in the medical record or is available to the care team, and/or that a surrogate decision maker was or was not identified.

  • If the patient is unable to name a surrogate decision maker or does not wish to discuss an advance care plan, document it as this qualifies also as a “performance met” criteria.

MIPS Measure: #134 Depression Screening and Follow Up

Patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen.

Documentation Requirement

Follow-Up Plan:
Documented follow-up for a positive depression screening must include one or more of the following:

  • Additional evaluation for depression
  • Suicide Risk Assessment
  • Referral to a practitioner who is qualified to diagnose and treat depression
  • Pharmacological interventions
  • Other interventions or follow-up for the diagnosis or treatment of depression

The follow-up plan must be related to a positive depression screening, example: 
“Patient referred for psychiatric evaluation due to positive depression screening”.

MIPS Measure #130: Documentation of Current Medications in the Medical Record

For all Medicare patients ≥18 years of age.

Documentation Requirement

  • You must document that you have obtained, reviewed, or updated the patient’s current medications.

MIPS Measure: #76 Central Venous Catheter ‐ Maximal Sterile Technique

Many emergency physician groups have not placed a central line in years, due to increased use of interosseous infusion or the increased availability of specialists to perform the procedures.

However, when a central line is placed, this measure seeks to determine that all elements of maximal sterile barrier technique (cap, mask, sterile gown, sterile gloves and sterile full body drape) were followed, including hand hygiene, skin preparation and, if ultrasound is used, that sterile ultrasound techniques were followed.

Documentation Requirement

The physician must make statements to the following effect:

  • “Maximal sterile technique was followed” during the procedure.
  • “Sterile technique was limited due to…” (an emergent case where aseptic technique would unacceptably delay the CVC insertion, or other harm could be caused). The clinical reason for not following aseptic technique must be clear in the record.

MIPS Measure: #226 Smoking Cessation Intervention Performed

Medicare currently pays separately, about $13, for CPT code 99406 to be reported when the emergency physician spends greater than 3 minutes in face-to-face discussion with a patient about the many aspects of why and how to stop smoking.

Most busy emergency physicians do not take the time to document this service, but it pays to do so. This measure effectively gives extra quality credit to a treating emergency physician who already has done enough to warrant the extra payment for the smoking cessation service.

The only time it is reportable is when you have already performed the smoking cessation service.

Documentation Requirement

CPT code 99406 can only be reported to Medicare when:

  • Documentation supports that the patient is alert and competent
  • The physician attests to the amount of time spent in this intervention
  • The cessation plan that was recommended to the patient is evident
  • The patient’s response to the face-to-face discussion is documented.

Example of acceptable documentation for 99406: “Counseled patient regarding smoking cessation for 5 min, script for patch provided, patient was receptive.

MIPS Measure #317: Screening for Pre-Hypertension and Hypertension with Follow Up

This measure determines how often you refer patients aged 18 years or older for follow-up by another provider when the last blood pressure taken in the ED is at or above 120 systolic, 80 diastolic.

While this pressure parameter is not what most emergency physicians would use to determine the need for follow-up. It is the parameter set by the U.S Preventive Services Task Force for pre-hypertensive as well as hypertensive patients and is followed by Medicare for this measure.

Documentation Requirement

Your chart must reflect all of the following to correctly report the measure:

  • A blood pressure must appear somewhere in the chart. If it is below the target parameters, we may report that patient as excluded from the follow-up criteria. If a pressure is not present in the parts of the chart available to us we must report that the measure was not met.
  • If the discharge blood pressure (the one least likely to be artificially high) is at or above the target, clear assertion must be present that the patient was referred for follow-up. You do not need to designate where follow-up can be obtained. The follow-up recommendation may be found in the discharge instructions but those must be available to the coder for you to be credited for performance. We recommend that this not be a templated conditional statement.
    “If your blood pressure is…” would not be an acceptable statement.
  • If the patient has an active diagnosis of hypertension, even if you are not treating it, the chart must reflect it so that we may report that patient as excluded from the measure requirement.
  • If the patient presents with an urgent or emergent medical condition, we will identify this from your overall documentation and report the case as an exclusion. The measure definition does not require a follow-up recommendation in these cases.

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