CMS innovation center models, home visit for patient assessment performed by clinical staff for an individual not considered homebound, including, but not necessarily limited to patient assessment of clinical status, safety/fall prevention, functional status/ambulation, medication reconciliation/management, compliance with orders/plan of care, performance of activities of daily living, and ensuring beneficiary connections to community and other services. (for use only in medicare-approved cms innovation center models); may not be billed for a 30 day period covered by a transitional care management code
Received instruction from the anesthesiologist or proxy prior to the day of surgery to abstain from smoking on the day of surgery
Antibiotic regimen prescribed
Radiation exposure indices documented in final report for procedure using fluoroscopy
Radiation exposure indices not documented in final report for procedure using fluoroscopy, reason not given
Documentation of medical reason for not performing foot exam (i.e., patients who have had either a bilateral amputation above or below the knee, or both a left and right amputation above or below the knee before or during the measurement period)
Documented reason for not assessing hepatitis B virus (HBV) status (e.g., patient not initiating anti-TNF therapy, patient declined) prior to initiating anti-TNF therapy
Antibiotic regimen prescribed within 10 days after onset of symptoms for documented medical reason
Documentation that the patient is on a statin medication or has documentation of a valid contraindication or exception to statin medications; contraindications/exceptions that can be defined by diagnosis codes include pregnancy during the measurement period, active liver disease, rhabdomyolysis, end stage renal disease on dialysis and heart failure; provider documented contraindications/exceptions include breastfeeding during the measurement period, woman of child-bearing age not actively taking birth control, allergy to statin, drug interaction (HIV protease inhibitors, nefazodone, cyclosporine, gemfibrozil, and danazol) and intolerance (with supporting documentation of trying a statin at least once within the last 5 years or diagnosis codes for myostitis or toxic myopathy related to drugs)
Documentation that the patient is not on a statin medication