Documentation Requirements

2018 MIPS Measures for Clinical Decision Units (CDU) & Observation Units

2018 MIPS Measures for Clinical Decision Units (CDU) & Observation Units

MIPS Measure: #47 Advanced Care Plan

For all Medicare patients ≥65 years of age with an initial and subsequent inpatient or initial H&P billed.

Documentation Requirement

The physician must make statements to the following effect:

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.

Measure: #76 Central Venous Catheter ‐ Maximal Sterile Technique

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 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.

This measure effectively gives extra quality credit to a treating 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.”

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