Multiple Sclerosis Quality Measurement Set 2020 Update

Multiple Sclerosis

Quality Measurement Set

2020 Update

Approved by the Multiple Sclerosis Quality Measure Development Work Group on September 1, 2020.

Approved by the AANI Quality Measure Subcommittee on September 10, 2020. Approved by AANI

Quality Committee on October 13, 2020. Approved by AANI Board of Directors on November 5, 2020.

Disclaimer

Quality Measures published by the American Academy of Neurology Institute and its affiliates are

assessments of current scientific and clinical information provided as an educational service. The

information: 1) should not be considered inclusive of all proper treatments, methods of care, or as a

statement of the standard of care; 2) is not continually updated and may not reflect the most recent

evidence (new evidence may emerge between the time information is developed and when it is published

or read); 3) addresses only the question(s) or topic(s) specifically identified; 4) does not mandate any

particular course of medical care; and 5) is not intended to substitute for the independent professional

judgment of the treating provider, as the information does not account for individual variation among

patients. In all cases, the selected course of action should be considered by the treating provider in the

context of treating the individual patient. Use of the information is voluntary. AANI provides this

information on an “as is” basis, and makes no warranty, expressed or implied, regarding the information.

AANI specifically disclaims any warranties of merchantability or fitness for a particular use or purpose.

AANI assumes no responsibility for any injury or damage to persons or property arising out of or related

to any use of this information or for any errors or omissions.

Limited proprietary coding is contained in the measure specifications for convenience. Users of the

proprietary coding sets should obtain all necessary licenses from the owners of these code sets. The AANI

and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®)

Standards Development Organization

©2020.  American Academy of Neurology Institute.  All Rights Reserved. 
CPT® Copyright 2004-2020 American Medical Association. 
3 
Contents 
Work Group Members .................................................................................................................................. 4 
Importance and Prevalence ........................................................................................................................... 5 
Defining Multiple Sclerosis Quality Measures ......................................................................................... 5 
Prevalence and Impact .......................................................................................................................... 5 
Measure Development Process ............................................................................................................. 5 
2020 Multiple Sclerosis (MS) Quality Measurement Set ............................................................................. 6 
2014 Multiple Sclerosis Quality Measures Retired .................................................................................. 6 
Other Potential Measures .......................................................................................................................... 8 
Measure Harmonization ............................................................................................................................ 8 
Introductory References ............................................................................................................................ 8 
2020 Multiple Sclerosis (MS) Quality Measure Specifications .................................................................... 9 
Magnetic Resonance Imaging (MRI) Monitoring for Patients with Multiple Sclerosis (MS) .................. 9 
Disease Modifying Therapies (DMT) Monitoring for Patients with Multiple Sclerosis (MS) ............... 15 
Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with Multiple Sclerosis 
(MS) ........................................................................................................................................................ 21 
Cognitive Impairment Screening and Follow-Up for Patients with Multiple Sclerosis (MS) ................ 30 
Fatigue Screening and Follow-Up for Patients with Multiple Sclerosis (MS) ....................................... 39 
Exercise and Appropriate Physical Activity Counseling for Patients with Multiple Sclerosis (MS) ..... 47 
Contact Information .................................................................................................................................... 52 
Appendix A: Disclosures ............................................................................................................................ 53 

Work Group Members

American Academy of Neurology

Alex Rae-Grant, MD, FRCPC, FAAN

Neeta Garg, MD

Barbara Giesser, MD, FAAN

Iris Vanessa Marin Collazo, MD

Michael Olek, DO

Consortium of Multiple Sclerosis Centers

Jeffrey English, MD

Multiple Sclerosis Association of America

Amanda Montague, EdM

National Multiple Sclerosis Society

Lilyana Amezcua, MD, MS, FAAN

Elizabeth Page

American Academy of Neurology Facilitators - non-voting work group members

Tracie Caller, MD

Adam G. Kelly, MD, FAAN

American Academy of Neurology Staff

Amy Bennett, JD

Molly Byrne, MPH

Erin Lee

Karen Lundgren, MBA

Brandon Magliocco, MS

Piper Ranallo, PhD

Becky Schierman, MPH

Importance and Prevalence

Defining Multiple Sclerosis Quality Measures

The American Academy of Neurology Institute (AANI) has developed quality measures since 2008 based on the belief

that specialists should play a major role in selecting and creating measures that will drive performance improvement and

possibly be used in accountability programs in the future. In 2014, the AANI developed a set of multiple sclerosis quality

measures, which was released in 2015 and reaffirmed on July 29, 2017. In 2019, the AANI formed a standing Multiple

Sclerosis (MS) Quality Measurement Set Work Group (work group). The AANI charged this work group with updating

existing and developing new quality measures for patients diagnosed with multiple sclerosis.

Additionally, the Work Group is charged with the surveillance of evolving evidence base to determine if future updates

are needed, as well as development and release of quality improvement tools to assist in the implementation of the

measures in practice. The work group will meet twice yearly to review any new guideline or evidence developments and

testing data. This will allow for more timely updates and maintenance of measures for use in public reporting and

accountability programs.

Prevalence and Impact

The estimated cumulated prevalence of MS among adults in the United States in 2010 was approximately 727,000. In

2017, that number was substantially higher, approximately 914,000.

1,2

The prevalence is higher among women with a

female: male ratio of 2.8.

A recent study found that multiple sclerosis health care spending in the United States was $13.9 billion in 2016.

Multiple

sclerosis was one of the health conditions with the highest annual spending growth paid by both public and private

insurance for the year, which may be correlated with the introduction of specialty drug treatment.

Measure Development Process

The AANI identified non-voting facilitators from the Quality Measure Subcommittee and Quality Committee to provide

methodological support and guide the work group to consensus decisions. A call for work group volunteers was made and

a subject matter expert Chair was identified. Work group members were selected based on review of disclosure

statements, subject matter expertise, and measure development experience. All work group members are required to

disclose relationships with industry and other entities to avoid actual, potential, or perceived conflicts of interest. Seated

work group members were instructed to abstain from voting on individual measure concepts if a conflict was present. See

Appendix A.

The AANI measure development process involves a modified Delphi review by the work group to reach consensus on

measures to be developed prior to a 21-day public comment and following the public comment for further refinement.

The measures in this set are being made available without any prior testing. The AAN encourages testing of this

measurement set for feasibility and reliability by organizations or individuals positioned to do so. Select measures will be

beta tested once the set has been released, prior to submission to the Centers for Medicare & Medicaid Services (CMS)

for consideration in Quality Payment Program’s (QPP) Merit-based Incentive Payment System (MIPS) and the National

Quality Forum for possible endorsement. The measurement set will be reviewed for updates at least every six months by

the standing multiple sclerosis measure development work group.

Below is an illustration of the measure development process from proposals, discussion, research, evaluation, to approval.

2020 Multiple Sclerosis (MS) Quality Measurement Set

The work group approved six measures for the 2020 update.

Magnetic Resonance Imaging (MRI) Monitoring for Patients with MS

Disease Modifying Therapies (DMT) Monitoring for Patients with MS

Bladder, Bowel, and Sexual Dysfunction Screening and Follow-up for Patients with MS

Cognitive Impairment Screening and Follow-up for Patients with MS

Fatigue Screening and Follow-up for Patients with MS

Exercise and Appropriate Physical Activity Counseling for Patients with MS

There is no requirement that all the measures in the measurement set be used. Providers and treatment teams are

encouraged to identify the one or two measures that would be most meaningful to their patient population and implement

those measures to drive performance improvement in practice. Data should be collected for an initial benchmark period,

and results used to drive meaningful changes to improve performance and overall care.

2014 Multiple Sclerosis Quality Measures Retired

Seven of the original multiple sclerosis quality measures were retired. Measures may be retired for multiple reasons, and

retirement does not reflect a lack of value in quantifying a concept. The work group strongly believes these concepts

remain of value, but measures were retired due to feasibility concerns or existence of cross-cutting measures that include

patients with MS in the denominator. The AANI is encouraging quality measurement development work groups to reduce

the number of measures available for an individual disease topic to reduce clinician burden, focus on fewer meaningful

measures for quality improvement, and allow for testing of measures developed. Rationale for individual measure

retirement is detailed in the following section:

11 Existing Measures Due

for Triennial Review

3 new concepts advanced

6 measures approved

Data Review via Concept

Rankings

Public comment and

Refinement

Group Discussions

5 new measures advanced

1 measure reaffirmed

2 additional measures

retired

Medical librarian search

Existing measure decisions

• 1 measure

reaffirmed

• 5 measures retired

• 4 measures

identified for

updates

• 1 measure held for

further discussion

25 new concepts identified

Multiple Sclerosis (MS) Diagnosis – Retired in 2020

Current MS Disability Scale Score – Retired in 2020

Fall Risk Screening for Patients with MS – Retired in 2020

Fatigue Outcome for Patients with MS - Retired in 2020

Clinical Depression Screening for Patients with MS – Retired in 2020

Depression Outcome for Patients with MS – Retired in 2020

Maintained or Improved Baseline Quality of Life for Patients with MS – Retired in 2020

• Multiple Sclerosis (MS) Diagnosis – The work group retired the MS diagnosis measure because the data

collection for these measures placed large burden on physicians and care provider teams including potentially

modifying their documentation practices.

• Current MS Disability Scale Score – This measure was previously incorporated in the AANI’s Axon Registry.

Implementation concerns were identified as the data were being collected in the registry. It was noted that some of

the disability scales approved for use in the measure would not be collected on the date of the patient visit and

collected at a later follow-up visit. CMS had approved the measure for use by a Qualified Clinical Data Registry

through 2019 following which, CMS added a modification to include a follow-up component to the collection of

the scale score. Adding a follow-up component would add another layer of complexity reducing feasibility

further. The work group noted that an outcome measure would be difficult to develop on the topic given the

varied scale use by neurologists and by practice settings. Given these concerns, the measure was retired and

discussion held on development of a relapse or disability related measure.

• Fall Risk Screening for Patients with MS – The work group retired this measure given the existence of cross-

cutting falls measures. The work group encourages providers to utilize one of the below measures to monitor and

track falls and fall outcomes in practice. MIPS Quality measure specifications are available at qpp.cms.gov.

o For patients 65 and older

▪ MIPS Quality ID #318 Falls: Screening for Future Fall Risk

▪ MIPS Quality ID #154 Falls: Risk Assessment

▪ MIPS Quality ID #155 Falls: Plan of Care

o For patients 64 and younger

▪ Axon Registry #45 Falls Outcome

▪ Axon Registry #53 Falls Plan of Care

• Fatigue Outcome for Patients with MS – The fatigue outcome measure was retired due to concerns that a

physician or MS treatment team has little control over changes in fatigue screening scores that are likely impacted

by multiple causes including other co-morbid conditions treated by other specialists. As a result, the measure was

changed to a screening and follow-up measure.

• Clinical Depression Screening for Patients with MS & Depression Outcome for Patients with MS – The work

group retired the prior depression assessment and outcome measures given the existence of cross-cutting

depression measures. The work group encourages providers to utilize one of the below measures to monitor and

track depression outcomes in practice:

o MIPS Quality ID #134 Preventive Care and Screening: Screening for Depression and Follow Up Plan

o MIPS Quality ID#370 Depression Remission at Twelve Months. Outcome measures at twelve months for

patients age 18 years and older diagnosed with major depression or dysthymia utilizing PHQ-9 scores

• Maintained or Improved Baseline Quality of Life for Patients with MS – The work group retired the prior quality

of life for patients with MS measure due to the existence of cross-cutting measures addressing quality of life for

patients with MS. The work group encourages providers to utilize Axon Registry #54 Quality of Life for Patients

with Neurologic Conditions.

Other Potential Measures

The work group proposed 25 measure concepts based on extensive literature search/review. The AANI encourages work

groups to focus development of measure concepts that are feasible to collect, do not pose an excessive burden on

providers to collect data, meaningful to quality improvement efforts, and address a known treatment or care gap. It is

important to recognize the fact that it is not feasible for the work group to develop all the appropriate concepts due to

resource limitations and consideration for minimizing provider reporting burden.

Through one round of ranking, work group members prioritized three newer concepts for discussion. Two concepts on

disease modifying therapy and fatigue screening were developed for public comment. One concept, relapse or disability

monitoring for patients with MS was not. This concept of relapse and disability monitoring is of utmost importance. The

determination to not make a measure at this time is detailed below. The work group plans to monitor this space to

determine if a measure can be developed during a future update of the measurement set.

Three relapse or disability options were discussed:

• a process measure assessing disability,

• an intermediate patient reported outcome focused on missed work or school days, and

• an intermediate patient reported outcome focused on healthcare utilization for relapses.

The above three concepts were not advanced to public comment due to feasibility concerns. The work group noted the

existing disability scale score measure was difficult to collect in practice and a new process measure would have similar

issues/limitations. Any intermediate patient reported outcome measure would require substantial practice and

documentation changes to implement. These concerns prevent any such measure from being developed at this time. The

work group will continue to revisit this concept during biannual reviews.

Measure Harmonization

The AANI encourages work groups to avoid duplication of measures that already exist in the field. Further details on

measure harmonization is included in individual measure specifications below.

The measurement set includes measures that require the use of validated screening tools. The work group discussed and

determined that multiple tools should be offered to allow providers to determine which tool best meets their individual

practice needs. Tools may be subject to copyright and require licensing fees. The work group notes that effective

September 2020 that Montreal Cognitive Assessment use requires completion of a proprietary examination and fee.

The AANI has developed additional measures that may be of interest to clinicians and teams treating patients with

neurologic conditions. All AANI measures are available for free at: https://www.aan.com/policy-and-

guidelines/quality/quality-measures2/quality-measures/

Introductory References

1. Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States. Neurology.

2019;92(10):e1029-e1040.

2. Nelson LM, Wallin MT, Marrie RA, et al. A new way to estimate neurologic disease prevalence in the United

States. Neurology. 2019; 92(10): 469-480.

3. Dieleman JL, Cao J, Chapin A, et al. US Health Care Spending by Payer and Health Condition, 1996-2016.

JAMA. 2020; 323(9):863-884.

4. Quality Measure Subcommittee. American Academy of Neurology Quality Measurement Manual 2019 Update.

24p. January 2020. Available at: https://www.aan.com/policy-and-guidelines/quality/quality-measures2/how-

measures-are-developed/ Accessed on November 13, 2020.

2020 Multiple Sclerosis (MS) Quality Measure Specifications

Magnetic Resonance Imaging (MRI) Monitoring for Patients with Multiple Sclerosis (MS)

Measure Title

MRI Monitoring for Patients with MS

Description

Percentage of patients who had a brain MRI scan in the last 24 months and care management

decisions updated.

Measurement

Period

January 1, 20xx to December 31, 20xx

Eligible

Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD),

Physician Assistant (PA), Advanced Practice Registered Nurse (APRN)

Care Setting(s)

Outpatient Care

Ages

Any

Event

Office or telehealth encounter

Diagnosis

Multiple Sclerosis

Denominator

Patients with a diagnosis of MS

Numerator

Patients who had a brain MRI scan in the last 24 months and care management decisions

updated*.

Definition

*Care management decisions updated defined as reaffirmation or adjustment to the

treatment plan, adjustment or initiation of appropriate medication, or further testing.

Required

Exclusions

• Active diagnosis of Radiologically Isolated Syndrome (RIS) or Clinically Isolated

Syndrome (CIS) on date of encounter

Allowable

Exclusions

• Patient declines referral to MRI in the last 24 months

• MRI not clinically indicated given patient circumstances on date of encounter

• Patient unable to have an MRI and this reason documented during measurement period

Allowable

Exclusion

Inclusion Logic

Allowable exclusions can only help measure performance. If a patient has an allowable

exclusion but is found to meet the numerator that patient is included in the count to meet the

measure.

Exclusion

Rationale

Patients with RIS and CIS are not included in the eligible population given the lack of guidelines

on timing of periodic surveillance imaging, as well as diagnostic variability for these conditions.

A required exclusion is appropriate as a result.

Allowable exclusions are needed for the following reasons:

• Patients must agree to undergo an MRI, and it is not appropriate to force a patient to

undergo testing they are opposed to having done. There are multiple reasons a patient

may decline MRI including claustrophobia, unable to access MRI due to limited MRI

availability, religious preference, and cost.

• MRI may not be clinically indicated for some patients and physician and treatment team

judgement should allow for these patients being excluded. Some examples of where

MRI is not clinically indicated include patients who have a 20-year history of MS or

current diagnosis of a progressive form of MS.

• Patient may meet an exclusion for MRI given a history of trauma or surgery which may

have left ferromagnetic material in the body, ferromagnetic implants or pacemakers, and

inability to lie still for 1 hour or more. These patients are appropriate to exclude due to

the potential harm that may result from undergoing an MRI. Also, if a patient is actively

having a clinical relapse, MRI may not add to clinical decision making about changing

the treatment regimen.

Measure Scoring

Percentage

Interpretation of

Score

Higher Score Indicates Better Quality

Measure Type

Process

Level of

Measurement

Provider

Risk Adjustment

Not Applicable

Opportunity to

Improve Gap in

Care

This measure is not intended to monitor baseline or re-baseline activity specifically. The

measure is intended to address a gap in care for patients and prompt providers to consider

modifying management decisions based on imaging results. The MRI changes may not always

prompt treatment modifications, but providers consider the MRI data to assess if they are

indicated in an individual patient. There are patients with MS who may require more frequent

monitoring such as those prescribed natalizumab to monitor for Progressive Multifocal

Leukoencephalopathy (PML) or those switching disease-modifying therapies; these patients

should be treated in accordance with current guideline statements.

The work group notes this measure may have a positive, unintended consequence of addressing

rural disparities by ensuring all patients with MS are provided routine MRI monitoring.

Monitoring of measure performance will occur to address any negative, unintended

consequences.

For Process

Measures

Relationship to

Desired Outcome

The following evidence statements are quoted verbatim from the referenced clinical guidelines:

• “Timing of brain MRI protocol for patients with an established diagnosis of MS:

…Every 1-2 years while on disease-modifying therapy to assess for subclinical disease

activity (i.e. new T2 lesions or gadolinium enhancing lesions). Less frequent MRI scans

required in clinically stable patients after 2-3 years of stable treatment (gadolinium-

based contrast optional)”

Harmonization

with Existing

Measures

Other draft measures impacting MRI use for patients with multiple sclerosis were reviewed; the

draft measures utilize different denominator based on subtypes of multiple sclerosis. The work

group developed this measure with a denominator of all patients with MS to address feasibility

of data collection in practice, as MS subtypes are not easily identified due to lack of consistent

coding practices.

References

1. Consortium of Multiple Sclerosis Centers. Consortium of MS Centers MRI Protocol for the

Diagnosis and Follow-up of MS 2018 Revised Guidelines. Available at:

https://www.mscare.org/page/MRI_protocol Accessed on November 13, 2020.

Process

Comparison MRI scan

collected

Treatment team

intervention for

identified patients

Intermediate

Outcome

Disease activity &

progression identified

Treatment

modification/optimized

to reduce disease

activity

Outcome

Reduced disease

activity

Code System

Code

Code Description

Initial Population

CPT

99201-99205

Office or other outpatient visit, new patient

CPT

99211-99215

Office or other outpatient visit, established patient

CPT

99241-99245

Office or other outpatient consultation, new or established patient

CPT

Telehealth TBD

Denominator

ICD-10

G35

Multiple Sclerosis

SNOMEDCT

24700007

Multiple sclerosis (disorder)

SNOMEDCT

192929006

Exacerbation of multiple sclerosis (disorder)

SNOMEDCT

230372003

Acute relapsing multiple sclerosis (disorder)

SNOMEDCT

425500002

Secondary progressive multiple sclerosis (disorder)

SNOMEDCT

426373005

Relapsing remitting multiple sclerosis (disorder)

SNOMEDCT

428700003

Primary progressive multiple sclerosis (disorder)

SNOMEDCT

438511000

Benign multiple sclerosis (disorder)

SNOMEDCT

92926004

Multiple sclerosis of the brainstem (disorder)

SNOMEDCT

192927008

Multiple sclerosis of the spinal cord (disorder)

SNOMEDCT

439567002

Malignant multiple sclerosis (disorder)

SNOMEDCT

724778008

Progressive relapsing multiple sclerosis (disorder)

SNOMEDCT

733028000

Multiple sclerosis, ichthyosis, factor VIII deficiency syndrome (disorder)

SNOMEDCT

766246000

Marburg acute multiple sclerosis (disorder)

SNOMEDCT

816984002

Progressive multiple sclerosis (disorder)

Numerator – MRI component

CPT

70551

Magnetic resonance imaging, brain without contrast material

CPT

70553

Magnetic resonance imaging, brain without contrast material, followed by

contrast material and further sequences

SNOMEDCT

241601008

MRI of head

SNOMEDCT

702724004

MRI of head and neck with contrast

SNOMEDCT

29567006

MRI of brain and brain stem (procedure)

SNOMEDCT

395611000119106

MRI of brain and brain stem with contrast

SNOMEDCT

443603002

MRI of brain with contrast using isotropic resolution

SNOMEDCT

698355003

Magnetic resonance imaging for measurement of brain volume with

contrast

SNOMEDCT

3313508016

Magnetic resonance imaging of brain and brain stem with contrast

(procedure)

SNOMEDCT

3320261014

MRI of brain and brain stem with contrast

SNOMEDCT

3313509012

Magnetic resonance imaging of brain and brain stem with contrast

Numerator – Care management decisions updated component

SNOMEDCT

1779009018

Development of care plan

SNOMEDCT

1767604017

Development of care plan (procedure)

SNOMEDCT

1196083017

Development of individualized plan of care (procedure)

SNOMEDCT

1209518012

Development of individualized plan of care

SNOMEDCT

1228792012

Develops individualized plan of care

SNOMEDCT

566252018

Change of medication (procedure)

SNOMEDCT

282660014

Change of medication

SNOMEDCT

282659016

Medication changed

SNOMEDCT

750861000124112

Recommendation to change medication to lower cost therapeutic

equivalent (procedure)

SNOMEDCT

750871000124117

Recommendation to change medication to lower cost therapeutic

equivalent

SNOMEDCT

616161000124116

Recommendation to change medication dose form (procedure)

SNOMEDCT

616171000124111

Recommendation to change medication dose form

SNOMEDCT

616181000124114

Advice to change medication dose form

SNOMEDCT

616281000124118

Recommendation to change medication dose (procedure)

SNOMEDCT

616291000124115

Recommendation to change medication dose

SNOMEDCT

616301000124119

Advice to change medication dose

SNOMEDCT

616161000124116

Recommendation to change medication dose form (procedure)

SNOMEDCT

566927011

Referral for further care (procedure)

SNOMEDCT

283512014

Referral for further care

SNOMEDCT

183444007

Referral for further care (procedure)

SNOMEDCT

709318013

Provision of specialist further education (procedure)

SNOMEDCT

456380014

Provision of specialist further education

SNOMEDCT

706904013

Further opinion sought (finding)

SNOMEDCT

453917017

Further opinion sought

Presence of key phrases in clinical note may meet numerator component for Axon Registry.

Suggested key phrases to locate numerator component via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Treatment plan remains appropriate”

• “No treatment plan changes needed”

• “Treatment plan updated”

• “Treatment plan changed”

• “Further testing conducted”

• “Additional tests ordered”

• “Pharmacological updates made”

• “Initiated Disease Modifying Therapy”

• “Initiated DMT”

• “Adjusted DMT”

• “Medication adjusted”

• “Continue same DMT”

Required Exclusions

ICD-10

G36.9

Acute disseminated demyelination, unspecified

ICD-10

G37.8

Other specified demyelinating diseases of the central nervous system

ICD-10

G37.9

Demyelinating disease of the central nervous system, unspecified

SNOMEDCT

445967004

Clinically isolated syndrome

SNOMEDCT

2880226016

Clinically isolated syndrome (disorder)

SNOMEDCT

2883049010

Clinically isolated syndrome

SNOMEDCT

633651000124112

Clinically isolated syndrome of brainstem (disorder)

SNOMEDCT

633661000124114

Clinically isolated syndrome of brainstem

SNOMEDCT

3009685011

Monofocal clinically isolated syndrome (disorder)

SNOMEDCT

3009542010

Monofocal clinically isolated syndrome

SNOMEDCT

703622004

Monofocal clinically isolated syndrome

SNOMEDCT

703621006

Multifocal clinically isolated syndrome

SNOMEDCT

3009533015

Multifocal clinically isolated syndrome (disorder)

SNOMEDCT

3009313015

Multifocal clinically isolated syndrome

SNOMEDCT

3009649011

Polysymptomatic clinically isolated syndrome

SNOMEDCT

16415361000119105

Radiologically isolated syndrome

SNOMEDCT

3774704015

Radiologically isolated syndrome (disorder)

SNOMEDCT

3774703014

Radiologically isolated syndrome

Allowable Exclusions

SNOMEDCT

183932001

Procedure contraindicated (situation)

SNOMEDCT

397745006

Medical contraindication (finding)

SNOMEDCT

407563006

Treatment not tolerated (situation)

SNOMEDCT

428119001

Procedure not indicated (situation)

SNOMEDCT

408548005

Magnetic resonance imaging scan declined

SNOMEDCT

2612982013

Magnetic resonance imaging scan declined (situation)

SNOMEDCT

2160098019

Magnetic resonance imaging scan declined

SNOMEDCT

746791000124111

Recommendation refused by patient (situation)

SNOMEDCT

746801000124112

Recommendation refused by patient

SNOMEDCT

2608177018

Refused procedure - after thought (situation)

SNOMEDCT

284171012

Refused procedure - after thought

SNOMEDCT

183947005

Refused procedure - after thought (situation)

SNOMEDCT

2606319010

Refusal of treatment by patient (situation)

SNOMEDCT

169559019

Refusal of treatment by patient

SNOMEDCT

105480006

Refusal of treatment by patient (situation)

SNOMEDCT

2612741019

Refusal of treatment by parents (situation)

SNOMEDCT

1209841012

Refusal of treatment by parents

SNOMEDCT

2608092019

Refused procedure - parent's wish (situation)

SNOMEDCT

284172017

Refused procedure - parent's wish

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

183944003

Procedure refused (situation)

SNOMEDCT

183945002

Procedure refused for religious reason (situation)

SNOMEDCT

413310006

Patient non-compliant - refused access to services (situation)

SNOMEDCT

413311005

Patient non-compliant - refused intervention / support (situation)

SNOMEDCT

413312003

Patient non-compliant - refused service (situation)

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

416432009

Procedure not wanted (situation)

SNOMEDCT

443390004

Refused (qualifier value)

Presence of key phrases in clinical note may meet allowable exclusion component for Axon Registry.

Suggested key phrases to locate exclusions via Axon Registry

are included below. This list is not exhaustive and will

be updated annually if adopted into the Axon Registry:

• “Patient has clinically evident disease activity.”

• “Patient declines referral to MRI.”

• “Patient refuses referral to MRI.”

• “Patient refuses MRI.”

• “Patient declines MRI.”

• “MRI not clinically indicated.”

• “Patient history prevents MRI.”

• “Patient unable to have MRI.”

• “MRI contraindicated.”

• “Patient meets MRI exclusion.”

• “Patient has new Dx of MS; MRI not indicated.”

• “MRI not ordered due to patient cost concerns”

Yes

Flow Chart Diagram: MRI Surveillance for Patients with MS

Patient

INCLUDED in

Eligible

Population

Patient NOT

Included in

Eligible

Population

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

In the last 24 months, did patient have a brain

MRI scan and care management decisions

updated?

Did the patient have at least one new or

established visit with an eligible provider

during the measurement period?

Did patient have an active diagnosis of RIS

or CIS on the date of the visit?

Patient

INCLUDED in

Denominator

On date of encounter, did patient decline

MRI?

Remove from

denominator*

*Do not remove/exclude

if patient meets the

numerator

Did patient have a MS diagnosis on the

date of the visit?

On date of encounter, was MRI not

clinically indicated?

During the measurement period, was

there a notation patient meets MRI

exclusion?

Disease Modifying Therapies (DMT) Monitoring for Patients with Multiple Sclerosis (MS)

Measure Title

DMT Monitoring for Patients with MS

Description

Percentage of patients with MS prescribed a DMT who were screened for side effects and

compliance/adherence.

Measurement

Period

January 1, 20xx to December 31, 20xx

Eligible

Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD),

Physician Assistant (PA), Advanced Practice Registered Nurse (APRN)

Care Setting(s)

Outpatient Care

Ages

Any

Event

Office or telehealth encounter for patients with a DMT prescription

Diagnosis

Multiple Sclerosis

Denominator

Patients with a diagnosis of MS who were prescribed a new DMT during the measurement

period.

Numerator

Patients who were screened on date of encounter for:

• DMT side effects and

• compliance/adherence with DMT

Required

Exclusions

• Patient had a new DMT initiated on date of encounter

Allowable

Exclusions

• Patient declines a discussion on date of encounter

Allowable

Exclusion

Inclusion Logic

Allowable exclusions can only help measure performance. If a patient has an allowable

exclusion but is found to meet the numerator that patient is included in the count to meet the

measure.

Exclusion

Rationale

• Patients with a new DMT initiated on date of encounter should be excluded due to

insufficient exposure to drug to necessitate monitoring and may have been switched to a

new DMT on the date in which case no need for a full monitoring assessment of the

prior DMT.

• DMT monitoring requires assessment of subjective symptom that requires patient

cooperation to assess.

Measure Scoring

Percentage

Interpretation of

Score

Higher Score Indicates Better Quality

Measure Type

Process

Level of

Measurement

Provider

Risk Adjustment

Not Applicable

Opportunity to

Improve Gap in

Care

The work group notes there is limited evidence about gaps in care surrounding DMT monitoring

and documentation, but anecdotally believes gaps exist for both. Evidence indicates that patients

will self-report adherence and compliance concerns when using DMT for MS.

This current measure is focused on monitoring following a new DMT initiation. Future

iterations of the measure may evolve over time to include all DMT monitoring. The work group

will assess feasibility, documentation burden and unintended consequences during future

reviews.

For Process

Measures

Relationship to

Desired Outcome

By screening and monitoring patients with MS prescribed DMTs, clinicians will be able to

identify patients with side effects and patients who are not adhering to treatment. Once these

issues are identified, clinicians will be able to modify/alter treatment plans or propose measures

to address side effects and compliance/adherence issues to help improve outcomes and quality of

life.

Following evidence statements are quoted verbatim from the referenced clinical guidelines:

• “Level B Clinicians should monitor for medication adherence, AEs, tolerability, safety,

and effectiveness of the therapy in people with MS on DMTs.”

• “Level B Clinicians should follow up either annually or according to medication-

specific REMs in people with MS on DMTs.”

• “Level B Clinicians should discuss a change to noninjectable or less frequently

injectable DMTs in people with MS who report intolerable discomfort with the

injections or in those who report injection fatigue on injectable DMTs.”

Harmonization

with Existing

Measures

Other draft measures for patients with multiple sclerosis utilizing DMTs were reviewed; the

draft measures utilize different denominator based on subtypes of multiple sclerosis. The work

group developed this measure with a denominator of all patients with MS to address feasibility

of data collection in practice, as MS subtypes are not easily identified due to lack of consistent

coding practices.

References

1. McKay KA, Evans A, Fisk JD, et al. Disease-Modifying Therapies and Adherence in

Multiple Sclerosis: Comparing Patient Self-Report with Pharmacy Records.

Neuroepidemiology. 2017; 48:124-130.

2. Rae-Grant A, Day GS, Marrie RA, et al. Practice guideline recommendations summary:

Disease-modifying therapies for adults with multiple sclerosis. Neurology. 2018;

90(17):777-788.

Process

DMT initiated

DMT monitoring

Intermediate

Outcome

DMT adherence

DMT tolerability and

safety assessed

Outcome

DMT use and

adherence resulting in

decreased MS-disease

activity

Initial Population

CPT

99201-99205

Office or other outpatient visit, new patient

CPT

99211-99215

Office or other outpatient visit, established patient

CPT

99241-99245

Office or other outpatient consultation, new or established patient

CPT

Telehealth codes TBD

Denominator

ICD-10

G35

Multiple Sclerosis

SNOMEDCT

24700007

Multiple sclerosis (disorder)

SNOMEDCT

192929006

Exacerbation of multiple sclerosis (disorder)

SNOMEDCT

230372003

Acute relapsing multiple sclerosis (disorder)

SNOMEDCT

425500002

Secondary progressive multiple sclerosis (disorder)

SNOMEDCT

426373005

Relapsing remitting multiple sclerosis (disorder)

SNOMEDCT

428700003

Primary progressive multiple sclerosis (disorder)

SNOMEDCT

438511000

Benign multiple sclerosis (disorder)

SNOMEDCT

92926004

Multiple sclerosis of the brainstem (disorder)

SNOMEDCT

192927008

Multiple sclerosis of the spinal cord (disorder)

SNOMEDCT

439567002

Malignant multiple sclerosis (disorder)

SNOMEDCT

724778008

Progressive relapsing multiple sclerosis (disorder)

SNOMEDCT

733028000

Multiple sclerosis, ichthyosis, factor VIII deficiency syndrome (disorder)

SNOMEDCT

766246000

Marburg acute multiple sclerosis (disorder)

SNOMEDCT

816984002

Progressive multiple sclerosis (disorder)

AND presence of one of the below RxNorm codes for the first time in the patient record for the first time in the 12

months prior to the date of the encounter.

RxNorm

Reviewed annually

Glatiramer acetate

RxNorm

Reviewed annually

Interferon b-1a

RxNorm

Reviewed annually

Interferon b-1b

RxNorm

Reviewed annually

Pegylated interferon b-1a

RxNorm

Reviewed annually

Dimethyl fumarate

RxNorm

Reviewed annually

Fingolimod

RxNorm

Reviewed annually

Teriflunomide

RxNorm

Reviewed annually

Siponimod

RxNorm

Reviewed annually

Cladribine

RxNorm

Reviewed annually

Diroximel fumarate

RxNorm

Reviewed annually

Alemtuzumab

RxNorm

Reviewed annually

Natalizumab

RxNorm

Reviewed annually

Ocrelizumab

RxNorm

Reviewed annually

Ofatumumab

Numerator – Side effect component

SNOMED

2612797016

No drug side effect reported (situation)

SNOMED

1488760019

No drug side effect reported

SNOMED

395061001

No drug side effect reported

SNOMED

1769129019

Medication side effects present (finding)

SNOMED

1780402015

Medication side effects present

SNOMED

1787478017

Has shown side effects from medication

SNOMED

3013779011

Medication side-effect

SNOMED

401207004

Medication side effects present (finding)

SNOMED

2612971017

Medication stopped - side effect (situation)

SNOMED

1488709015

Medication stopped - side effect

SNOMED

395009001

Medication stopped – side effect (finding)

SNOMED

704417003

At risk of medication side effect (finding)

SNOMED

3013270011

At risk of medication side effect (finding)

SNOMED

3013275018

At risk of medication side effect

SNOMED

129850005

At risk for negative response to medication

SNOMED

2608043013

Doctor stopped drugs - side effect (situation)

SNOMED

282667012

Doctor stopped drugs - side effect

SNOMED

282668019

Dr stopped drugs - side effect

SNOMED

182842009

Doctor stopped drugs – side effect (situation)

SNOMED

552913018

High risk drug side effect (finding)

SNOMED

264902014

High risk drug side effect

SNOMED

170909007

High risk drug side effect (finding)

SNOMED

2719553017

Repeat prescription drug side effect (finding)

SNOMED

2770170014

Repeat prescription drug side effect

SNOMED

170926001

Repeat prescription drug side effect (finding)

SNOMED

2152188017

Drug side effect - acceptable to patient (finding)

SNOMED

2159921014

Drug side effect - acceptable to patient

SNOMED

408357000

Drug side effect - acceptable to patient (finding)

Presence of key phrases in clinical note may meet numerator component for Axon Registry.

Suggested key phrases to locate numerator components via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Patient reports no side effects”

• “Patient reports side effects”

• “DMT side effects discussed”

• “DMT side effects are severe”

• “DMT side effects are moderate”

• “DMT side effects are mild”

• “DMT side effects are minimal”

• “DMT side effects reported”

• “DMT side effects not reported”

• “DMT side effects are tolerable”

• “DMT side effects are improving”

Numerator - Medication adherence/compliance component:

SNOMED

2788859011

Compliance behavior to prescribed medication (observable entity)

SNOMED

2792744019

Compliance behavior to prescribed medication

SNOMED

2793641011

Compliance behaviour to prescribed medication

SNOMED

439914008

Compliance behavior to prescribed medication (observable entity)

SNOMED

3036826013

Compliance behavior to therapeutic regimen (observable entity)

SNOMED

3036723011

Compliance behavior to therapeutic regimen

SNOMED

3037872015

Compliance behaviour to therapeutic regimen

SNOMED

709007004

Compliance behavior to therapeutic regimen (observable entity)

SNOMED

1768899016

Drug compliance poor (finding)

SNOMED

1780186012

Drug compliance poor

SNOMED

400978007

Drug compliance poor (finding)

SNOMED

2152204014

Drug compliance checked (finding)

SNOMED

2159937015

Drug compliance checked

SNOMED

408373006

Drug compliance checked (finding)

SNOMED

2573535016

Verbalizes medication compliance (finding)

SNOMED

2576832015

Verbalizes medication compliance

SNOMED

2579791015

Verbalizes medication adherence

SNOMED

4190110006

Verbalizes medication compliance (finding)

SNOMED

566303015

Drug compliance good (finding)

SNOMED

282724013

Drug compliance good

SNOMED

182884001

Drug compliance good (finding)

SNOMED

1491000124115

Prescription compliance status (finding)

SNOMED

1501000124111

Prescription compliance status

SNOMED

671000124101

Prescription compliance status (finding)

SNOMED

5631000175104

Patient sequesters unused medication

SNOMED

2834718017

Assessment of compliance with medication regimen (procedure)

SNOMED

2471844010

Assessment of compliance with medication regimen

SNOMED

2477776019

Assess compliance with medication regimen

SNOMED

740391000124114

Assessment of adherence to medication regimen

SNOMED

410122002

Assessment of compliance with medication regimen (procedure)

SNOMED

2529544010

Drug therapy compliance observations (finding)

SNOMED

2576445011

Drug therapy compliance finding

SNOMED

2532949019

Drug therapy compliance observations

SNOMED

414059009

Drug therapy compliance observations (finding)

SNOMED

182884001

Drug compliance good

SNOMED

400978007

Drug compliance poor

SNOMED

408373006

Drug compliance checked

SNOMED

668770011

Drugs - total non-compliance (finding)

SNOMED

411900018

Drugs - total non-compliance

SNOMED

275927006

Drugs - total non-compliance (finding)

SNOMED

668771010

Drugs - partial non-compliance (finding)

SNOMED

411901019

Drugs - partial non-compliance

SNOMED

275928001

Drugs - partial non-compliance (finding)

SNOMED

709008009

Complies with therapeutic regimen

SNOMED

7058009

Noncompliance with treatment

SNOMED

2638881015

Noncompliance with treatment (finding)

SNOMED

2647221012

Noncompliance with treatment

SNOMED

2536432016

Does not comply with treatment

SNOMED

740101000124117

Nonadherence with treatment

SNOMED

734021017

Noncompliance with medication regimen (finding)

SNOMED

208675012

Noncompliance with medication regimen

SNOMED

208676013

Noncompliance: medication regimen

SNOMED

129834002

Noncompliance with medication regimen (finding)

SNOMED

3004395012

Non-compliance of drug therapy (finding)

SNOMED

3004295010

Non-compliance of drug therapy

SNOMED

726441000124114

Drug therapy non adherence

SNOMED

726431000124116

Medication therapy non-adherence

SNOMED

702565001

Non-compliance of drug therapy (finding)

SNOMED

778331000124111

Medication non-adherence due to intolerance (finding)

SNOMED

778341000124118

Medication non-adherence due to intolerance

SNOMED

778321000124113

Medication non-compliance due to intolerance

SNOMED

457621000124107

Medication non-adherence due to intolerance (finding)

SNOMED

3004326019

Suspected non-compliance of drug therapy (situation)

SNOMED

3449739016

Suspected non-adherence of medication therapy

SNOMED

3004393017

Suspected non-compliance of drug therapy

SNOMED

702566000

Suspected non-compliance of drug therapy (situation)

SNOMED

778351000124116

Medication non-adherence due to language barrier (finding)

SNOMED

778361000124119

Medication non-adherence due to language barrier

SNOMED

778371000124114

Medication non-compliance due to language barrier

SNOMED

457631000124105

Medication non-adherence due to language barrier (finding)

SNOMED

778381000124112

Medication non-adherence due to psychosocial issues (finding)

SNOMED

778391000124110

Medication non-adherence due to psychosocial issues

SNOMED

778401000124112

Medication non-compliance due to psychosocial issues

SNOMED

457641000124100

Medication non-adherence due to psychosocial issues (finding)

SNOMED

751831000124111

Medication non-compliance due to excessive pill burden (finding)

SNOMED

751841000124118

Medication non-compliance due to excessive pill burden

SNOMED

751851000124116

Medication non-adherence due to excessive pill burden

SNOMED

454171000124105

Medication non-compliance due to excessive pill burden (finding)

Presence of key phrases in clinical note may meet numerator component for Axon Registry.

Suggested key phrases to locate numerator components via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Patient taking DMT consistently”

• “Patient not taking DMT consistently”

• “Patient inconsistently taking DMT”

• “Patient not adherent with DMT”

• “Patient adherent with DMT”

• “Patient unable to afford DMT”

Required Exclusions

Presence of one of the above RxNorm codes for the first time in the patient record on the date of the encounter.

Allowable Exclusions

SNOMEDCT

2606319010

Refusal of treatment by patient (situation)

SNOMEDCT

169559019

Refusal of treatment by patient

SNOMEDCT

105480006

Refusal of treatment by patient (situation)

SNOMEDCT

2612741019

Refusal of treatment by parents (situation)

SNOMEDCT

1209841012

Refusal of treatment by parents

SNOMEDCT

183945002

Procedure refused for religious reason (situation)

SNOMEDCT

413310006

Patient non-compliant - refused access to services (situation)

SNOMEDCT

413311005

Patient non-compliant - refused intervention / support (situation)

SNOMEDCT

413312003

Patient non-compliant - refused service (situation)

SNOMEDCT

443390004

Refused (qualifier value)

Presence of key phrases in clinical note may meet allowable exclusion component for Axon Registry.

Suggested key phrases to locate exclusions via Axon Registry

are included below. This list is not exhaustive and will

be updated annually if adopted into the Axon Registry:

• “Patient declines to discuss DMT use”

• “Patient refuses to discuss DMT use”

Yes

Flow Chart Diagram: DMT Monitoring for Patients with MS

Patient

INCLUDED in

Eligible

Population

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

On date of encounter, was patient

prescribed a new DMT?

Remove from

denominator*

*Do not remove/exclude

if patient meets the

numerator

Did patient have a MS diagnosis on the date

of the visit?

On date of encounter, did patient decline or

refuse discussion on DMT use?

Was patient screened for DMT side effects, AND

medication adherence/non-compliance?

Patient

INCLUDED in

Denominator

Patient NOT

Included in

Eligible

Population

Did the patient have at least one new or

established visit with an eligible provider

during the measurement period?

Did patient have a new DMT prescribed

during the measurement period?

Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with Multiple Sclerosis (MS)

Measure Title

Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with MS

Description

Percentage of patients with MS who were screened for at least one of three symptoms: bladder,

bowel, or sexual dysfunction in the past 12 months, and if screening positive for any one of

these symptoms had appropriate follow-up care.

Measurement

Period

January 1, 20xx to December 31, 20xx

Eligible

Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD),

Physician Assistant (PA), Advanced Practice Registered Nurse (APRN),

Physical Therapy (PT), Occupational Therapy (OT)

Care Setting(s)

Outpatient Care

Ages

Any

Event

Office or telehealth encounter

Diagnosis

Multiple Sclerosis

Denominator

Patients with a diagnosis of MS.

Numerator

Patients with MS who were screened* for at least one of three symptoms: bladder, bowel, or

sexual dysfunction in the past 12 months, and if screening positive had appropriate follow-up**

care.

Definitions:

* Screened is defined as an assessment of symptoms.

**Appropriate follow-up is defined as adjustment to the treatment plan, adjustment or

initiation of appropriate medication, further testing, counseling on lifestyle changes, or

referral to an appropriate healthcare provider.

Required

Exclusions

None

Allowable

Exclusions

• Patient refuses or patient declines on date of encounter

Allowable

Exclusion

Inclusion Logic

Allowable exclusions can only help measure performance. If a patient has an allowable

exclusion but is found to meet the numerator that patient is included in the count to meet the

measure.

Exclusion

Rationale

• Patients need to be willing to complete the screening for the screening to be valid.

Measure Scoring

Percentage

Interpretation of

Score

Higher Score Indicates Better Quality

Measure Type

Process

Level of

Measurement

Provider

Risk Adjustment

Not Applicable

Opportunity to

Improve Gap in

Care

2010 North American Research Committee on Multiple Sclerosis (NARCOMS) Registry data

indicated that 91% of 9,341 patients with MS responding were mildly, moderately, or severely

bothered by bladder, bowel, or sexual symptoms.

Between 50 to 90% of men with MS and 40

to 80% of women with MS experience sexual dysfunction which is significantly more than in

general population

. Sexual dysfunction symptoms are often overlooked in clinical evaluations

of patients with MS.

Schairer, et al., found that sexual dysfunction has a larger detrimental

impact on the mental health of health-related quality of life for patients with MS than physical

disability.

For this first iteration of the measure a broad definition of screening was provided; clinicians

may use a validated instrument. The work group notes these instruments are not widely used in

practice. The measure may be updated in future reviews, to detail specific instruments as they

become more widely used in practice.

For Process

Measures

Relationship to

Desired Outcome

By screening annually for bladder, bowel, and sexual dysfunction, clinicians will be able to

identify patients needing appropriate treatment to address these issues, leading to improved

outcomes and better quality of life.

Following evidence statements are quoted verbatim from the referenced clinical guidelines or :

• “Ensure all people with MS have a comprehensive review of all aspects of their care at

least once a year.”

• “Tailor the comprehensive review to the needs of the person with MS assessing:

o …bladder, bowel, and sexual function…”

• “Refer any issues identified during the comprehensive review of the person with MS to

members of the MS multidisciplinary team and other appropriate teams so that they can

be managed.”

• “When assessing lower urinary tract dysfunction in a person with neurological disease,

take a clinical history, including information about:

o urinary tract symptoms

o neurological symptoms and diagnosis (if known)

o clinical course of the neurological disease

o bowel symptoms

o sexual function

o comorbidities

o use of prescription and other medication and therapies.”

• “Refer people for urgent investigation if they have any of the following ‘red flag’ signs

and symptoms:

o haematuria

o recurrent urinary tract infections (for example, three or more infections in the

last 6 months)

o loin pain

o recurrent catheter blockages (for example, catheters blocking within 6 weeks of

being changed)

o hydronephrosis or kidney stones on imaging

o biochemical evidence of renal deterioration.”

o “Be aware that unexplained changes in neurological symptoms (for example,

confusion or worsening spasticity) can be caused by urinary tract disease, and

consider further urinary tract investigation and treatment if this is suspected.”

• “Consider pelvic floor muscle training for people with: lower urinary tract dysfunction

due to multiple sclerosis….”

Fletcher, et al., state, “All MS patients should be specifically queried about sexual function.”

Further, they noted, “A variety of factors, including MS related disease activity, MS symptoms,

depression & effects of pharmacologic therapy can contribute to sexual dysfunction in patients

with MS.”

Harmonization

with Existing

Measures

No known similar measures

References

1. Wang G, Marrie RA, Fox RJ, et al. Treatment satisfaction and bothersome bladder, bowel, sexual

symptoms in multiple sclerosis. Multiple Sclerosis and Related Disorders. 2018; 20: 16-21.

2. Pöttgen J, Rose A, van de Vis W, et al. Sexual dysfunctions in MS in relation to

neuropsychiatric aspects and its psychological treatment: A scoping review. PLoS One.

2018;13(2):e0193381.

3. Schairer LC, Foley FW, Zemon V, et al. The impact of sexual dysfunction on health-

related quality of life in people with multiple sclerosis. Multiple Sclerosis. 2014;

20(5):610-616.

4. National Clinical Guideline Centre (NICE) (UK). Multiple Sclerosis: Management of Multiple

Sclerosis in Primary and Secondary Care. London: National Institute for Health and Care

Excellence; 2014 Oct. 2019 update available at: https://www.nice.org.uk/guidance/cg186

Accessed on November 13, 2020.

5. National Clinical Guideline Centre (NICE) (UK). Urinary incontinence in neurological

disease: assessment and management. London: National Institute for Health and Care

Excellence; 2012 Aug. Available at: https:/www.nice.org.uk/guidance/cg148 Accessed

on March 5, 2020.

6. Fletcher SG, Castro-Borrero W, Remington G, et al. Sexual dysfunction in patients with

multiple sclerosis: a multidisciplinary approach to evaluation and management. Nature

Clinical Practice Urology. 2009; 6: 96-107.

Process

Screening completed

Intermediate

Outcome

Treatment of bladder,

bowel, or sexual

dysfunction symptoms

Reduction of secondary

complications

Outcome

Improved quality of life

Reduction or

elimination of bladder,

bowel, and sexual

dysfunction symptoms

Code System

Code

Code Description

Initial Population

CPT

99201-99205

Office or other outpatient visit, new patient

CPT

99211-99215

Office or other outpatient visit, established patient

CPT

99241-99245

Office or other outpatient consultation, new or established patient

CPT

97003, 97004

Occupational therapy, evaluation and re-evaluation

CPT

97161-97164

Physical therapy, evaluation and re-evaluation

CPT

Telehealth codes TBD

Denominator

ICD-10

G35

Multiple Sclerosis

SNOMEDCT

24700007

Multiple sclerosis (disorder)

SNOMEDCT

192929006

Exacerbation of multiple sclerosis (disorder)

SNOMEDCT

230372003

Acute relapsing multiple sclerosis (disorder)

SNOMEDCT

425500002

Secondary progressive multiple sclerosis (disorder)

SNOMEDCT

426373005

Relapsing remitting multiple sclerosis (disorder)

SNOMEDCT

428700003

Primary progressive multiple sclerosis (disorder)

SNOMEDCT

438511000

Benign multiple sclerosis (disorder)

SNOMEDCT

92926004

Multiple sclerosis of the brainstem (disorder)

SNOMEDCT

192927008

Multiple sclerosis of the spinal cord (disorder)

SNOMEDCT

439567002

Malignant multiple sclerosis (disorder)

SNOMEDCT

724778008

Progressive relapsing multiple sclerosis (disorder)

SNOMEDCT

733028000

Multiple sclerosis, ichthyosis, factor VIII deficiency syndrome (disorder)

SNOMEDCT

766246000

Marburg acute multiple sclerosis (disorder)

SNOMEDCT

816984002

Progressive multiple sclerosis (disorder)

Numerator – Screening Component^

ICD-10

R37

Sexual Dysfunction

ICD-10

K59

Constipation

ICD-10

N32.81

Overactive Bladder

ICD-10

R32

Urinary Incontinence

ICD-10

R35

Nocturia

ICD-10

F52

Erectile Dysfunction

^New ICD-10 diagnostic code may meet the numerator if added on date of encounter

SNOMEDCT

777147011

Bladder dysfunction (finding)

SNOMEDCT

67519012

Bladder dysfunction

SNOMEDCT

639699011

Must urinate repeatedly to empty bladder (finding)

SNOMEDCT

371974010

Must urinate repeatedly to empty bladder

SNOMEDCT

1765650018

Neurogenic dysfunction of the urinary bladder (finding)

SNOMEDCT

1777342015

Neurogenic dysfunction of the urinary bladder

SNOMEDCT

1765983010

Neurogenic bladder (finding)

SNOMEDCT

1777632010

Neurogenic bladder

SNOMEDCT

624071012

Bowel dysfunction (disorder)

SNOMEDCT

353134013

Bowel dysfunction

SNOMEDCT

353133019

BD - Bowel dysfunction

SNOMEDCT

118202007

Finding of sexual function

SNOMEDCT

697616014

Finding of sexual function (finding)

SNOMEDCT

443249016

Finding of sexual function

SNOMEDCT

1220367013

Observation of sexual function

SNOMEDCT

795491010

Abnormal sexual function (finding)

SNOMEDCT

94664018

Abnormal sexual function

SNOMEDCT

1231659011

Sexual dysfunction

SNOMEDCT

613002013

Decreased sexual function (finding)

SNOMEDCT

339169010

Decreased sexual function

SNOMEDCT

339168019

Impaired sexual function

SNOMEDCT

65210015

Normal sexual function (finding)

SNOMEDCT

19904012

Normal sexual function

SNOMEDCT

788443011

Normal female sexual function (finding)

SNOMEDCT

84366014

Normal female sexual function

SNOMEDCT

823566017

Normal male sexual function (finding)

SNOMEDCT

136328013

Normal male sexual function

SNOMEDCT

758802014

Abnormal female sexual function (finding)

SNOMEDCT

47132019

Abnormal female sexual function

SNOMEDCT

792328019

Abnormal male sexual function (finding)

SNOMEDCT

10048011

Abnormal male sexual function

SNOMEDCT

3035843015

Male sexual dysfunction

Presence of key phrases in clinical note may meet numerator component for Axon Registry.

Suggested key phrases to locate numerator components via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Screened for GI symptoms; no follow-up needed”

• “Screened for GI symptoms; follow-up needed”

• “Screened for bladder symptoms; follow-up needed”

• “Screened for bladder symptoms; no follow-up needed”

• “Screened for bowel symptoms; follow-up needed”

• “Screened for bowel symptoms; no follow-up needed”

• “Screened for sexual dysfunction; follow-up needed”

• “Screened for sexual dysfunction; no follow-up needed”

Numerator – Follow-Up Component

SNOMEDCT

1779009018

Development of care plan

SNOMEDCT

1767604017

Development of care plan (procedure)

SNOMEDCT

1196083017

Development of individualized plan of care (procedure)

SNOMEDCT

1209518012

Development of individualized plan of care

SNOMEDCT

1228792012

Develops individualized plan of care

SNOMEDCT

566252018

Change of medication (procedure)

SNOMEDCT

282660014

Change of medication

SNOMEDCT

282659016

Medication changed

SNOMEDCT

750861000124112

Recommendation to change medication to lower cost therapeutic equivalent

(procedure)

SNOMEDCT

750871000124117

Recommendation to change medication to lower cost therapeutic equivalent

SNOMEDCT

616161000124116

Recommendation to change medication dose form (procedure)

SNOMEDCT

616171000124111

Recommendation to change medication dose form

SNOMEDCT

616181000124114

Advice to change medication dose form

SNOMEDCT

616281000124118

Recommendation to change medication dose (procedure)

SNOMEDCT

616291000124115

Recommendation to change medication dose

SNOMEDCT

616301000124119

Advice to change medication dose

SNOMEDCT

616161000124116

Recommendation to change medication dose form (procedure)

SNOMEDCT

616171000124111

Recommendation to change medication dose form

SNOMEDCT

616181000124114

Advice to change medication dose form

SNOMEDCT

223415003

Recommendation regarding activity (procedure)

SNOMEDCT

223440005

Recommendation to undertake activity (procedure)

SNOMEDCT

223469001

Discussion about activity (procedure)

SNOMEDCT

223415003

Recommendation regarding activity (procedure)

SNOMEDCT

566927011

Referral for further care (procedure)

SNOMEDCT

283512014

Referral for further care

SNOMEDCT

183444007

Referral for further care (procedure)

SNOMEDCT

709318013

Provision of specialist further education (procedure)

SNOMEDCT

456380014

Provision of specialist further education

SNOMEDCT

706904013

Further opinion sought (finding)

SNOMEDCT

453917017

Further opinion sought

SNOMEDCT

2463898019

Sexual behavior management (regime/therapy)

SNOMEDCT

1477096017

Sexual behavior management

SNOMEDCT

1490387018

Behavior management: sexual

SNOMEDCT

1490158013

Behaviour management: sexual

SNOMEDCT

1476135011

Sexual behaviour management

SNOMEDCT

567047012

Referred to urologist (finding)

SNOMEDCT

283665014

Referred to urologist

SNOMEDCT

705017017

Referral to gastroenterologist (procedure)

SNOMEDCT

451830012

Referral to gastroenterologist

SNOMEDCT

567043011

Referral to gynecology service (procedure)

SNOMEDCT

283659014

Referral to gynecology service

SNOMEDCT

283658018

Gynaecological referral

SNOMEDCT

283656019

Gynecological referral

SNOMEDCT

283657011

Referral to gynaecology service

SNOMEDCT

702506019

Referral to obstetrics and gynecology service (procedure)

SNOMEDCT

449028018

Referral to obstetrics and gynecology service

SNOMEDCT

449029014

Referral to obstetrics and gynaecology service

SNOMEDCT

2572866010

Urinary catheter care education (procedure)

SNOMEDCT

2471974018

Urinary catheter care education

SNOMEDCT

2477933010

Teach urinary catheter care

SNOMEDCT

2572868011

Urinary catheter irrigation education (procedure)

SNOMEDCT

2471980014

Urinary catheter irrigation education

SNOMEDCT

2477939014

Teach urinary catheter irrigation

Presence of key phrases in clinical note may meet numerator follow-up component for Axon Registry.

Suggested key phrases to locate follow-up via Axon Registry

are included below. This list is not exhaustive and will

be updated annually if adopted into the Axon Registry:

• “Behavioral modification”

• “Treatment plan updated”

• “Treatment changed”

• “Lifestyle changes”

• “Referral to urologist”

• “Referral to GI specialist”

• “Referral to OB/GYN”

• “Further testing conducted”

• “Additional tests ordered”

• “Pharmacological updates made”

• “Medication adjusted”

• “Catheter guidance provided”

• “Care instructions provided for catheter”

• “Clean intermittent self-catheterization”

Allowable Exclusions

SNOMEDCT

746791000124111

Recommendation refused by patient (situation)

SNOMEDCT

746801000124112

Recommendation refused by patient

SNOMEDCT

2608177018

Refused procedure - after thought (situation)

SNOMEDCT

284171012

Refused procedure - after thought

SNOMEDCT

183947005

Refused procedure - after thought (situation)

SNOMEDCT

2606319010

Refusal of treatment by patient (situation)

SNOMEDCT

169559019

Refusal of treatment by patient

SNOMEDCT

105480006

Refusal of treatment by patient (situation)

SNOMEDCT

2612741019

Refusal of treatment by parents (situation)

SNOMEDCT

1209841012

Refusal of treatment by parents

SNOMEDCT

2608092019

Refused procedure - parent's wish (situation)

SNOMEDCT

284172017

Refused procedure - parent's wish

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

183944003

Procedure refused (situation)

SNOMEDCT

183945002

Procedure refused for religious reason (situation)

SNOMEDCT

413310006

Patient non-compliant - refused access to services (situation)

SNOMEDCT

413311005

Patient non-compliant - refused intervention / support (situation)

SNOMEDCT

413312003

Patient non-compliant - refused service (situation)

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

416432009

Procedure not wanted (situation)

SNOMEDCT

443390004

Refused (qualifier value)

Presence of key phrases in clinical note may meet allowable exclusion component for Axon Registry.

Suggested key phrases to locate exclusions via Axon Registry

are included below. This list is not exhaustive and will

be updated annually if adopted into the Axon Registry:

• “Patient has declined screening”

• “Patient declines to discuss bladder, bowel, and sexual function”

• “Patient refuses to discuss bladder, bowel, and sexual function”

• “Patient refuses screening”

• “Patient declines screening”

Yes

Flow Chart Diagram: Bladder, Bowel, and Sexual Dysfunction Screening and Follow-Up for Patients with MS

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

On date of the encounter, was patient

screened for bladder, bowel, or sexual

dysfunction, and if screen positive, had

appropriate follow-up care?

Patient

INCLUDED in

Eligible

Population

Patient NOT

Included in

Eligible

Population

Did the patient have at least one new or

established visit with an eligible provider

during the measurement period?

Did patient have a MS diagnosis on the date

of the visit?

Patient

INCLUDED in

Denominator

On date of encounter, did patient decline or

refuse screening?

Remove from

denominator*

*Do not remove/exclude

if patient meets the

numerator

Cognitive Impairment Screening and Follow-Up for Patients with Multiple Sclerosis (MS)

Measure Title

Cognitive Impairment Screening and Follow-Up for Patients with MS

Description

Percentage of patients with MS who were screened* for cognitive impairment in the past 12

months and if screening positive, patient was referred appropriately for further evaluation and

management.

Measurement

Period

January 1, 20xx to December 31, 20xx

Eligible

Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD),

Assistant (PA), Advanced Practice Registered Nurse (APRN), Physical

Therapy (PT), Occupational Therapy (OT)

Care Setting(s)

Outpatient Care

Ages

Any

Event

Office or telehealth encounter

Diagnosis

Multiple Sclerosis

Denominator

All patients with a diagnosis of MS.

Numerator

Patients with MS were screened* for cognitive impairment in past 12 months, and if screening

positive, patient was referred appropriately for further evaluation and management**.

Definitions:

* Screened is defined as administering any one of the following tools:

• Brief International Assessment of Cognition for MS (BICAMS),

• Symbol Digit Modalities Test (SDMT),

• MS Neuropsychological Screening Questionnaire (MSNQ) Observer version,

• Computerized Speed Cognitive Test (CST),

• Processing Speed Test (PST),

• Verbal fluency (phonemic and semantic),

• Paced Auditory Serial Addition Test (PASAT),

• Rao Brief Repeatable Neuropsychological Battery (BRNB),

• Minimal Assessment of Cognitive Function in MS (MACFIMS),

• PROMIS,

• Montreal Cognitive Assessment (MoCA).

7-9

**Further evaluation and management is defined as referral to:

• MS neuropsychological rehabilitation

• Neuropsychologist or psychologist,

• Speech/language pathologist, or

• Occupational therapist.

Neuropsychological evaluation in the past 12 months, may be used to meet the

numerator for screening and evaluation and management.

Required

Exclusions

• Patient not seen in past 12 months

Allowable

Exclusions

• Patient declines to complete a cognitive assessment on date of encounter.

• Patient is not able to complete a cognitive assessment on date of encounter.

• Patient currently receiving treatment to address cognitive impairment.

Allowable

Exclusion

Inclusion Logic

Allowable exclusions can only help measure performance. If a patient has an allowable

exclusion but is found to meet the numerator that patient is included in the count to meet the

measure.

Exclusion

Rationale

• Patients who have not been seen in the past 12 months are appropriate to exclude as

cognitive screening could not be completed in the required timeframe.

• Patients need to be willing to complete the screening tool for the screening scores to be

valid.

• Patients may be unable to meaningfully participate in a cognitive assessment and

exclusion is appropriate for those in a coma, delirious, or severely cognitively impaired.

• Screening would not be needed for those currently receiving treatment for a cognitive

impairment previously identified.

Measure Scoring

Percentage

Interpretation of

Score

Higher Score Indicates Better Quality

Measure Type

Process

Level of

Measurement

Provider

Risk Adjustment

Not applicable

Opportunity to

Improve Gap in

Care

43-70% of people with MS have reported cognitive impairments.

Clinicians cannot detect

cognitive impairment unless there is regular assessment. Clinical interview and standard

neurological examination is not sufficiently sensitive to detect cognitive impairment in multiple

sclerosis, and suggests need for a brief, accurate cognitive screening.

Screening should start

early, given the potential for cognitive impairment to start early for patients with MS and

appropriate referrals provided for positive results or changes.

11, 3

The Mini Mental Status Exam was not included in the list of screening tools due to concerns the

tool is not sufficiently sensitive to the most common cognitive deficits seen in patients with

MS.

For Process

Measures

Relationship to

Desired Outcome

Cognitive functioning impacts life satisfaction and health-related quality of life. It is anticipated

that if assessed on an ongoing basis, cognitive deficits may be identified and addressed in a

timely manner. Once identified, such deficits could be treated (or patients referred to

appropriate resources) and thereby improve individuals’ quality of life.

Following evidence statements are quoted verbatim from the referenced clinical guidelines:

• For adults and children (8+ years of age) with clinical or magnetic resonance imaging

(MRI) evidence of neurologic damage consistent with MS: As a minimum, early

baseline screening with the Symbol Digit Modalities Test (SDMT) or similarly validated

test, when the patient is clinically stable” (Consensus statement)

• For adults and children (8+ years of age) with clinical or magnetic resonance imaging

(MRI) evidence of neurologic damage consistent with MS: Annual re-assessment with

the same instrument, or more often as needed to (1) detect acute disease activity; (2)

assess for treatment effects (e.g. starting/changing a disease modifying therapy) or for

relapse recovery; (3) evaluate progression of cognitive impairment; and/or (4) screen for

new-onset cognitive problems.” (Consensus statement)

• For adults (18+ years): more comprehensive assessment for anyone who tests positive

on initial cognitive screening or demonstrates significant cognitive decline, especially if

there are concerns about comorbidities or the individual is applying for disability due to

cognitive impairment.” (Consensus statement)

• “Appropriate management of cognitive dysfunction in MS includes education for people

with MS and their family members, early screening and ongoing monitoring throughout

the disease course, and interventions to remediate dysfunction and provide

compensatory strategies to optimize function and participation.”(Consensus statement)

• “…is recommended to assess areas of cognitive deficit and strength, as well as to

evaluate all factors that could be impacting cognitive functioning, such as cognitive

reserve, depression and/or anxiety fatigue, co-morbid health conditions, and

medications.”(Consensus statement)

• Patients who require rehabilitation to address cognitive changes impacting their

functioning at home or at work should be referred to a specialist. The optimal referral is

to a specialist in MS neuropsychological rehabilitation (neuropsychologist,

speech/language pathologist or occupational therapist)… .”(Consensus statement)

• “Tailor the comprehensive review to the needs of the person with MS assessing: MS

symptoms: …cognitive symptoms…”

• “Be aware that the symptoms of MS can include cognitive problems, including memory

problems that the person may not immediately recognise or associate with their MS.”

• “Talk to people with MS and their family members or carers about the possibility that

the condition might lead to cognitive problems.”

• “Consider referring people with MS and persisting memory or cognitive problems to

both an occupational therapist and a neuropsychologist to assess and manage these

symptoms.”

Harmonization

with Existing

Measures

There are no known cognitive impairment quality measures that incorporate patients with MS in

the denominator. A measure is needed to address the opportunity for improvement specific to

the cognitive impairments faced by the MS population.

References

1. Benedict RHB, Amato MP, Boringa J, et al. Brief International Cognitive Assessment for MS

(BICAMS): international standards for validation. BMC Neurology. 2012;12:55.

2. Smith A. The symbol-digit modalities test: a neuropsychologic test of learning and other cerebral

disorders. J. Helmuth (Ed.) Learning disorders, Special Child Publications, Seattle (1968), pp.

83-91.

3. Kalb R, Beier M, Benedict RH, et al. Recommendations for cognitive screening and management

in multiple sclerosis care. Multiple Sclerosis. 2018; 24(13):1665-1680.

4. Connick P, Kolappan M, Bak TH, et al. Verbal fluency as a rapid screening test for cognitive

impairment in progressive multiple sclerosis. J Neurol Neurosurg Psychiatry. 2012;83(3):346-

347.

5. Foley FW, Benedict RHB, Gromisch ES, et al. The Need for Screening, Assessment, and

Treatment for Cognitive Dysfunction in Multiple Sclerosis. Results of a Multidisciplinary CMSC

Consensus Conference, September 24, 2010. Int J MS Care. 2012;14:58–64.

6. Becker H, Stuifbergen A, Lee H, et al. Reliability and Validity of PROMIS Cognitive Abilities

and Cognitive Concerns Scales Among People with Multiple Sclerosis. Int J MS Care.

2014;16(1):1-8.

7. Freitas S, Batista S, Afonso A, et al. The Montreal Cognitive Assessment (MoCA) as a screening

test for cognitive dysfunction in MS. Appl Neuropsychol Adult. 2018;25(1):57-70.

8. Dagenais E, Roulou I, Demers M, et al. Value of the MoCA as a screening instrument in multiple

sclerosis. Can J Neurol Sci. 2013; 40(3):410-415.

9. Kaur D, Kumer G, Singh A. Quick screening of cognitive function in Indian multiple sclerosis

patients using Montreal cognitive assessment test-short version. Ann Indian Acad Neurol.

2013;16(4);585-589.

10. Langdon DW, Amato MP, Boringa J, et al. Recommendations for a Brief International

Cognitive Assessment for Multiple Sclerosis (BICAMS). Multiple Sclerosis. 2012;0(0);1-8.

11. Romero K, Shammi P, Feinstein A. Neurologist Accuracy and Predicting Cognitive Impairment

in Multiple Sclerosis. Multiple Sclerosis and Related Disorders. 2015;15(4):291–295.

Process

Cognitive impairment

screening completed

Intermediate

Outcome

Cognitive impairment

treatment initiated

Outcome

Improved quality of life

12. Beatty WW and Goodkin DE. Screening for Cognitive Impairment in Multiple Sclerosis: An

Evaluation of the Mini-Mental State Examination. Arch Neurol. 1990;47(3):297-301.

13. National Clinical Guideline Centre (NICE) (UK). Multiple Sclerosis: Management of Multiple

Sclerosis in Primary and Secondary Care. London: National Institute for Health and Care

Excellence; 2014 Oct. 2019 update available at: https://www.nice.org.uk/guidance/cg186

Accessed on November 13, 2020.

Code System

Code

Code Description

Initial Population

CPT

99201-99205

Office or other outpatient visit, new patient

CPT

99211-99215

Office or other outpatient visit, established patient

CPT

99241-99245

Office or other outpatient consultation, new or established patient

CPT

97003, 97004

Occupational therapy, evaluation and re-evaluation

CPT

97161-97164

Physical therapy, evaluation and re-evaluation

CPT

Telehealth codes TBD

Denominator

ICD-10

G35

Multiple Sclerosis

SNOMEDCT

24700007

Multiple sclerosis (disorder)

SNOMEDCT

192929006

Exacerbation of multiple sclerosis (disorder)

SNOMEDCT

230372003

Acute relapsing multiple sclerosis (disorder)

SNOMEDCT

425500002

Secondary progressive multiple sclerosis (disorder)

SNOMEDCT

426373005

Relapsing remitting multiple sclerosis (disorder)

SNOMEDCT

428700003

Primary progressive multiple sclerosis (disorder)

SNOMEDCT

438511000

Benign multiple sclerosis (disorder)

SNOMEDCT

92926004

Multiple sclerosis of the brainstem (disorder)

SNOMEDCT

192927008

Multiple sclerosis of the spinal cord (disorder)

SNOMEDCT

439567002

Malignant multiple sclerosis (disorder)

SNOMEDCT

724778008

Progressive relapsing multiple sclerosis (disorder)

SNOMEDCT

733028000

Multiple sclerosis, ichthyosis, factor VIII deficiency syndrome (disorder)

SNOMEDCT

766246000

Marburg acute multiple sclerosis (disorder)

SNOMEDCT

816984002

Progressive multiple sclerosis (disorder)

Numerator – Screened component

LOINC

81529-0

PROMIS short form - cognitive function 6a - version 2.0

LOINC

81532-4

PROMIS short form - cognitive function 6a - version 2.0 raw score

LOINC

81530-8

PROMIS short form - cognitive function 8a - version 2.0

LOINC

81531-6

PROMIS short form - cognitive function 8a - version 2.0 raw score

LOINC

81534-0

PROMIS short form - cognitive function - abilities subset 4a - version 2.0

raw score

LOINC

81526-6

PROMIS short form - cognitive function - abilities subset 6a - version 2.0

LOINC

81535-7

PROMIS short form - cognitive function - abilities subset 6a - version 2.0

raw score

LOINC

81527-4

PROMIS short form - cognitive function - abilities subset 8a - version 2.0

LOINC

81536-5

PROMIS short form - cognitive function - abilities subset 8a - version 2.0

raw score

LOINC

81528-2

PROMIS short form - cognitive function 4a - version 2.0

LOINC

81525-8

PROMIS short form - cognitive function - abilities subset 4a - version 2.0

LOINC

72172-0

Total score [MoCA]

LOINC

72133-2

Montreal Cognitive Assessment [MoCA]

LOINC

84436-5

Pattern Comparison Processing Speed Test [NIH Toolbox]

LOINC

84483-7

Pattern Comparison Processing Speed Test - national percentile [NIH

Toolbox]

LOINC

84486-0

Pattern Comparison Processing Speed Test - raw score [NIH Toolbox]

LOINC

84484-5

Pattern Comparison Processing Speed Test - scale score age adjusted [NIH

Toolbox]

LOINC

84485-2

Pattern Comparison Processing Speed Test - scale score fully adjusted

[NIH Toolbox]

LOINC

84487-8

Pattern Comparison Processing Speed Test - unadjusted scale score [NIH

Toolbox]

SNOMEDCT

666547011

Symbol digit modalities test (assessment scale)

SNOMEDCT

409521019

Symbol digit modalities test

SNOMEDCT

409522014

SDMT - Symbol digit modalities test

SNOMEDCT

3310099013

Symbol Digit Modalities Test score (observable entity)

SNOMEDCT

3310105010

Symbol Digit Modalities Test score

SNOMEDCT

3311106017

SDMT (Symbol Digit Modalities Test) score

SNOMEDCT

3305110019

Assessment using Symbol Digit Modalities Test (procedure)

SNOMEDCT

3305111015

Assessment using Symbol Digit Modalities Test

SNOMEDCT

3307589015

Assessment using SDMT (Symbol Digit Modalities Test)

SNOMEDCT

708044014

Paced auditory serial addition test (assessment scale)

SNOMEDCT

455064017

Paced auditory serial addition test

SNOMEDCT

455063011

PASAT - Paced auditory serial addition test

SNOMEDCT

1785144016

PASAT - Paced auditory stimulation test

SNOMEDCT

1785145015

Paced auditory stimulation test

SNOMEDCT

3725598019

Paced Auditory Serial Addition Test score (observable entity)

SNOMEDCT

3725600013

Paced Auditory Serial Addition Test score

SNOMEDCT

3725752017

PASAT-Paced Auditory Serial Addition Test score

SNOMEDCT

3725599010

Paced Auditory Stimulation Test score

SNOMEDCT

3725598019

Paced Auditory Serial Addition Test score (observable entity)

SNOMEDCT

790891000124112

Assessment using Montreal cognitive assessment (procedure)

SNOMEDCT

790901000124111

Assessment using Montreal cognitive assessment

SNOMEDCT

790871000124111

MoCA Assessment

SNOMEDCT

790911000124114

Montreal cognitive assessment

SNOMEDCT

790831000124113

Montreal cognitive assessment score (observable entity)

SNOMEDCT

790821000124110

Montreal cognitive assessment score

SNOMEDCT

790841000124115

MoCA score

SNOMEDCT

1460984013

Impaired cognition (finding)

SNOMEDCT

1480926019

Impaired cognition

SNOMEDCT

1491798012

Cognitive decline

SNOMEDCT

3289770014

Cognitive deficit

SNOMEDCT

1491796011

Cognitive disturbance

SNOMEDCT

1491797019

Cognitive dysfunction

SNOMEDCT

1491795010

Cognitive impairment

SNOMEDCT

621379018

Minimal cognitive impairment (finding)

SNOMEDCT

175146011

Minimal cognitive impairment

SNOMEDCT

3006637011

Moderate cognitive impairment (finding)

SNOMEDCT

3006646017

Moderate cognitive impairment

SNOMEDCT

3006674010

Severe cognitive impairment (finding)

SNOMEDCT

3006632017

Severe cognitive impairment

SNOMEDCT

751741000124113

Cognitive impairment due to multiple sclerosis (disorder)

SNOMEDCT

751781000124119

Cognitive impairment due to multiple sclerosis

SNOMEDCT

751811000124117

Cognitive deficit due to multiple sclerosis

Presence of key phrases in clinical note may meet numerator screening component for Axon Registry.

Suggested key phrases to locate screening component via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Brief International Assessment of Cognition for MS completed and f/u needed”

• “BICAMS completed and f/u needed”

• “Brief International Assessment of Cognition for MS completed and f/u not needed”

• “BICAMS completed and f/u not needed”

• “Symbol Digit Modalities Test completed and f/u needed”

• “SDMT completed and f/u needed”

• “Symbol Digit Modalities Test completed and f/u not needed”

• “SDMT completed and f/u not needed”

• “MS Neuropsychological Screening Questionnaire - Observer version completed and f/u needed”

• “MSNQ completed and f/u needed”

• “MS Neuropsychological Screening Questionnaire - Observer version completed and f/u not needed”

• “MSNQ completed and f/u not needed”

• “Computerized Speed Cognitive Test completed and f/u needed”

• “CST completed and f/u needed”

• “Computerized Speed Cognitive Test completed and f/u not needed”

• “CST completed and f/u not needed”

• “Processing Speed Test completed and f/u needed”

• “PST completed and f/u needed”

• “Processing Speed Test completed and f/u not needed”

• “PST completed and f/u not needed”

• “Verbal fluency completed and f/u needed”

• “Verbal fluency completed and f/u not needed”

• “Paced Auditory Serial Addition Test completed and f/u needed”

• “PASAT completed and f/u needed”

• “Paced Auditory Serial Addition Test completed and f/u not needed”

• “PASAT completed and f/u not needed”

• “Rao Brief Repeatable Neuropsychological Battery completed and f/u needed”

• “BRNB completed and f/u needed”

• “Rao Brief Repeatable Neuropsychological Battery completed and f/u not needed”

• “BRNB completed and f/u not needed”

• “Minimal Assessment of Cognitive Function in MS completed and f/u needed”

• “MACFIMS completed and f/u needed”

• “Minimal Assessment of Cognitive Function in MS completed and f/u not needed”

• “MACFIMS completed and f/u not needed”

• “PROMIS completed and f/u needed”

• “PROMIS completed and f/u not needed”

• “Montreal Cognitive Assessment completed and f/u needed”

• “Montreal Cognitive Assessment completed and f/u not needed”

• “Neuropsychological exam results reviewed”

Numerator – Follow-up component

CPT

99483

Cognitive Impairment and Care Plan Assessment

CPT

96136, 96138,

96146

Neuropsychological testing

CPT

96116

Neurobehavioral status exam

SNOMEDCT

308459004

Referral to psychologist (procedure)

SNOMEDCT

308477009

Referral to psychiatrist (procedure)

SNOMEDCT

81294000

Patient referral for psychotherapy (procedure)

SNOMEDCT

88848003

Psychiatric follow-up (procedure)

SNOMEDCT

309627007

Child referral - clinical psychologist (procedure)

SNOMEDCT

2546404011

Referral for neuropsychological testing (procedure)

SNOMEDCT

2548695019

Referral for neuropsychological testing

SNOMEDCT

704991010

Referral to speech and language therapist (procedure)

SNOMEDCT

451792012

Referral to speech and language therapist

SNOMEDCT

451791017

Refer to speech therapist

SNOMEDCT

702758011

Referral to community-based speech and language therapist (procedure)

SNOMEDCT

449359011

Referral to community-based speech and language therapist

SNOMEDCT

449360018

Referral to community speech and language therapist

SNOMEDCT

702551019

Referral to speech and language therapy service (procedure)

SNOMEDCT

449090019

Referral to speech and language therapy service

SNOMEDCT

702552014

Referral to community-based speech and language therapy service

(procedure)

SNOMEDCT

449091015

Referral to community-based speech and language therapy service

SNOMEDCT

449092010

Referral to community speech and language therapy service

SNOMEDCT

750281000124115

Referral for occupational therapy (procedure)

SNOMEDCT

750291000124117

Referral for occupational therapy

SNOMEDCT

702543017

Referral to occupational therapy service (procedure)

SNOMEDCT

449079012

Referral to occupational therapy service

SNOMEDCT

2788042017

Referral to pediatric occupational therapy service (procedure)

SNOMEDCT

2792715016

Referral to pediatric occupational therapy service

SNOMEDCT

2792714017

Referral to paediatric occupational therapy service

SNOMEDCT

702544011

Referral to community-based occupational therapy service (procedure)

SNOMEDCT

449080010

Referral to community-based occupational therapy service

SNOMEDCT

449081014

Referral to community occupational therapy service

Presence of key phrases in clinical note may meet numerator follow-up component for Axon Registry.

Suggested key phrases to locate follow-up component via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Referral to MS neuropsychological rehabilitation”

• “Referral to neuropsychologist”

• “Referral to psychologist”

• “Referral to speech pathologist”

• “Referral to speech/language pathologist”

• “Referral to occupational therapist”

• “Referred to MS neuropsychological rehabilitation”

• “Referred to neuropsychologist”

• “Referred to psychologist”

• “Referred to speech pathologist”

• “Referred to speech/language pathologist”

• “Referred to occupational therapist”

• “Neuropsychological exam results reviewed”

Required Exclusions

A required exclusion for patient not seen in prior 12 months before encounter would be calculated using CPT codes

above in initial population.

Allowable Exclusions

SNOMEDCT

746791000124111

Recommendation refused by patient (situation)

SNOMEDCT

746801000124112

Recommendation refused by patient

SNOMEDCT

2608177018

Refused procedure - after thought (situation)

SNOMEDCT

284171012

Refused procedure - after thought

SNOMEDCT

183947005

Refused procedure - after thought (situation)

SNOMEDCT

2606319010

Refusal of treatment by patient (situation)

SNOMEDCT

169559019

Refusal of treatment by patient

SNOMEDCT

105480006

Refusal of treatment by patient (situation)

SNOMEDCT

2612741019

Refusal of treatment by parents (situation)

SNOMEDCT

1209841012

Refusal of treatment by parents

SNOMEDCT

2608092019

Refused procedure - parent's wish (situation)

SNOMEDCT

284172017

Refused procedure - parent's wish

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

183944003

Procedure refused (situation)

SNOMEDCT

183945002

Procedure refused for religious reason (situation)

SNOMEDCT

413310006

Patient non-compliant - refused access to services (situation)

SNOMEDCT

413311005

Patient non-compliant - refused intervention / support (situation)

SNOMEDCT

413312003

Patient non-compliant - refused service (situation)

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

416432009

Procedure not wanted (situation)

SNOMEDCT

443390004

Refused (qualifier value)

Presence of key phrases in clinical note may meet allowable exclusion for Axon Registry.

Suggested key phrases to locate allowable exclusions via Axon Registry

are included below. This list is not exhaustive

and will be updated annually if adopted into the Axon Registry:

• “Patient declines cognitive assessment”

• “Patient is not able to complete a cognitive assessment”

• “Patient unable to complete cognitive assessment”

• “Patient currently receiving treatment to address cognitive impairment.”

• “Patient currently receiving treatment for cognitive impairment”

• “Patient receiving cognitive impairment care from other provider”

Yes

Flow Chart Diagram: Cognitive Impairment Screening and Follow-Up for Patients with MS

Patient

INCLUDED in

Eligible

Population

Patient

INCLUDED in

Denominator

On date of encounter, did patient decline or

refuse a cognitive screening?

Did patient have a MS diagnosis on the date

of the visit?

Patient NOT

Included in

Eligible

Population

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

Was patient screened for cognitive impairment in

past 12 months, and if screening positive were

provided appropriate follow-up?

Did the patient have at least one new or

established visit with an eligible provider

during the measurement period?

On the date of the encounter, was the

patient unable to complete a cognitive

screening?

Remove from

denominator*

*Do not remove/exclude

if patient meets the

numerator

Is the patient currently receiving treatment

for a cognitive impairment?

Was patient seen previously in the 12

months prior to the date of the visit?

Fatigue Screening and Follow-Up for Patients with Multiple Sclerosis (MS)

Measure Title

Fatigue Screening and Follow-Up for Patients with MS

Description

Percentage of patients 18 years and older with diagnosis of MS who were screened for fatigue in

past 12 months, and if screening positive were provided appropriate follow-up.

Measurement

Period

January 1, 20xx to December 31, 20xx

Eligible

Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Pharmacist (PharmD),

Physician Assistant (PA), Advanced Practice Registered Nurse (APRN),

Physical Therapy (PT), Occupational Therapy (OT)

Care Setting(s)

Outpatient Care

Ages

18 and older

Event

Office or telehealth encounter

Diagnosis

Multiple Sclerosis

Denominator

Patients 18 years and older with a diagnosis of MS.

Numerator

Patients with MS who were screened* for fatigue in past 12 months, and if screening positive

were provided appropriate follow-up.**

Definitions

*Screened is defined as use of one of the following validated fatigue rating instruments:

• the Fatigue Severity Scale (FSS)

1-4

• Modified Fatigue Impact Scale

5,6

• Shortened Modified Fatigue Impact Scale

**Follow-up for this measure is defined as adjustment to the treatment plan, adjustment or

initiation of appropriate medication, further testing, referral to PT/OT, exercise program,

lifestyle modification program, or referral to an appropriate healthcare provider.

Required

Exclusions

None

Allowable

Exclusions

• Patients unable to complete a fatigue screening on date of encounter

• Patient declines to complete a fatigue screening on date of encounter

Allowable

Exclusion

Inclusion Logic

Allowable exclusions can only help measure performance. If a patient has an allowable

exclusion but is found to meet the numerator that patient is included in the count to meet the

measure.

Exclusion

Rationale

• Fatigue is a subjective symptom that requires patient cooperation to assess.

Measure Scoring

Percentage

Interpretation of

Score

Higher Score Indicates Better Quality

Measure Type

Process

Level of

Measurement

Provider

Risk Adjustment

Not Applicable

Opportunity to

Improve Gap in

Care

Fatigue occurs in about 80% of patients with MS reducing physical activity and level of daily

functioning.

It is anticipated that by addressing fatigue, quality of life will improve as

individuals have decreased fatigue and increased ability to function at work and home.

For Process

Measures

Relationship to

Desired Outcome

The desired outcome is to reduce or eliminate fatigue in MS patients. The measure will provide

an incentive for providers to identify and manage fatigue in MS patients.

The following evidence statements are quoted verbatim from the referenced clinical guidelines:

• “Assess and offer treatment to people with MS who have fatigue for anxiety, depression,

difficulty in sleeping, and any potential medical problems such as anaemia or thyroid

disease.”

• “Explain that MS-related fatigue may be precipitated by heat, overexertion and stress or

may be related to the time of day.”

• “Advise people that aerobic, balance and stretching exercises including yoga may be

helpful in treating MS-related fatigue.

”8

Harmonization

with Existing

Measures

There are currently no other comparable fatigue measures in national measurement programs or

endorsed by the National Quality Forum.

References

Krupp LB, LaRocca NG, Nuir-Nash J, et al. The Fatigue Severity Scale: Application to Patients with

Multiple Sclerosis and Systemic Lupus Erythematosus. Arch Neurol. 1989;46(10):1121-1123.

Christodoulou C, MacAllister WS, Krupp LB: Psychiatry for Neurologists: Fatigue 295-306

Philadelphia: Elsevier Science; 2003.

Schwartz JE, Jandorf L, Krupp LB. The measurement of fatigue: A new instrument. Journal of

Psychosomatic Research. 1993; 37(7):753-762.

Téllez N, Río J, Tintoré M, et al. Does the Modified Fatigue Impact Scale offer a more comprehensive

assessment of fatigue in MS? Mult Scler. 2005 11: 198.

5 Fisk JD, Pontefract A, Ritvo PG, Archibald CJ, Murray TJ. The impact of fatigue on patients with

multiple sclerosis. Can J Neurol Sci. 1994; 21: 9-14.

Ritvo PG, Fischer JS, Miller DM, et al. Multiple Sclerosis Quality of Life Inventory (MSQLI): A User’s

Manual. New York: The Consortium of Multiple Sclerosis Centers Health Services Research

Subcommittee, National Multiple Sclerosis Society, New York, 1997.

Meads DM, Doward LC, McKenna SP, et al. The development and validation of the Unidimensional

Fatigue Impact Scale (U-FIS). Multiple Sclerosis. 2009; 15(10):1228-1238.

National Clinical Guideline Centre (NICE) (UK). Multiple Sclerosis: Management of Multiple Sclerosis

in Primary and Secondary Care. London: National Institute for Health and Care Excellence; 2014 Oct.

2019 update available at: https://www.nice.org.uk/guidance/cg186 Accessed on November 13, 2020.

Process

Fatigue screening

completed

Intermediate

Outcome

Fatigue symptoms

identified

Treatment initiated for

fatigue symptoms

Outcome

Reduction of fatigue

symptoms

Improved quality of life

Code System

Code

Code Description

Initial Population

CPT

99201-99205

Office or other outpatient visit, new patient

CPT

99211-99215

Office or other outpatient visit, established patient

CPT

99241-99245

Office or other outpatient consultation, new or established patient

CPT

97003, 97004

Occupational therapy, evaluation and re-evaluation

CPT

97161-97164

Physical therapy, evaluation and re-evaluation

CPT

Telehealth codes TBD

Denominator

ICD-10

G35

Multiple Sclerosis

SNOMEDCT

24700007

Multiple sclerosis (disorder)

SNOMEDCT

192929006

Exacerbation of multiple sclerosis (disorder)

SNOMEDCT

230372003

Acute relapsing multiple sclerosis (disorder)

SNOMEDCT

425500002

Secondary progressive multiple sclerosis (disorder)

SNOMEDCT

426373005

Relapsing remitting multiple sclerosis (disorder)

SNOMEDCT

428700003

Primary progressive multiple sclerosis (disorder)

SNOMEDCT

438511000

Benign multiple sclerosis (disorder)

SNOMEDCT

92926004

Multiple sclerosis of the brainstem (disorder)

SNOMEDCT

192927008

Multiple sclerosis of the spinal cord (disorder)

SNOMEDCT

439567002

Malignant multiple sclerosis (disorder)

SNOMEDCT

724778008

Progressive relapsing multiple sclerosis (disorder)

SNOMEDCT

733028000

Multiple sclerosis, ichthyosis, factor VIII deficiency syndrome (disorder)

SNOMEDCT

766246000

Marburg acute multiple sclerosis (disorder)

SNOMEDCT

816984002

Progressive multiple sclerosis (disorder)

Numerator -Screened component

LOINC

28100-6

Fatigue

SNOMEDCT

3039531019

Assessment of fatigue (procedure)

SNOMEDCT

3039553017

Assessment of fatigue

SNOMEDCT

2879783014

Fatigue impact scale score (observable entity)

SNOMEDCT

2883110010

Fatigue impact scale score

Presence of key phrases in clinical note may meet numerator component for Axon Registry.

Suggested key phrases to locate numerator component via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “FSS results indicate f/u needed”

• “FSS results indicate no f/u needed”

• “Modified Fatigue Impact Scale

results indicate f/u needed”

• “Modified Fatigue Impact Scale

results indicate no f/u needed”

• “MFIS

results indicate f/u needed”

• “MFIS

results indicate no f/u needed”

• “MFIS-5 results indicate f/u needed”

• “MFIS-5 results indicate no f/u needed”

Numerator -Follow-up needed for positive screening component

Follow-up is required when the FSS score is greater than or equal to 5 and when the MFIS score is greater than or

equal to 39. The work group will evaluate adding future cutoffs for the SMFIS should this data be published.

SNOMEDCT

826028019

Fatigue (finding)

Presence of key phrases in clinical note may meet numerator component for Axon Registry.

Suggested key phrases to locate numerator component via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “FSS results indicate f/u needed”

• “FSS score is 5 [or greater]”

• “Modified Fatigue Impact Scale

results indicate f/u needed”

• “MFIS

results indicate f/u needed”

• “MFIS score is 39 [or greater]”

• “Shortened Modified Fatigue Impact Scale

results indicate f/u needed”

• “MFIS-5 indicates f/u needed”

Numerator -Follow-up component

SNOMEDCT

1779009018

Development of care plan

SNOMEDCT

1767604017

Development of care plan (procedure)

SNOMEDCT

1196083017

Development of individualized plan of care (procedure)

SNOMEDCT

1209518012

Development of individualized plan of care

SNOMEDCT

1228792012

Develops individualized plan of care

SNOMEDCT

566252018

Change of medication (procedure)

SNOMEDCT

282660014

Change of medication

SNOMEDCT

282659016

Medication changed

SNOMEDCT

750861000124112

Recommendation to change medication to lower cost therapeutic

equivalent (procedure)

SNOMEDCT

750871000124117

Recommendation to change medication to lower cost therapeutic

equivalent

SNOMEDCT

616161000124116

Recommendation to change medication dose form (procedure)

SNOMEDCT

616171000124111

Recommendation to change medication dose form

SNOMEDCT

616181000124114

Advice to change medication dose form

SNOMEDCT

616281000124118

Recommendation to change medication dose (procedure)

SNOMEDCT

616291000124115

Recommendation to change medication dose

SNOMEDCT

616301000124119

Advice to change medication dose

SNOMEDCT

616161000124116

Recommendation to change medication dose form (procedure)

SNOMEDCT

616171000124111

Recommendation to change medication dose form

SNOMEDCT

616181000124114

Advice to change medication dose form

SNOMEDCT

223415003

Recommendation regarding activity (procedure)

SNOMEDCT

223440005

Recommendation to undertake activity (procedure)

SNOMEDCT

223469001

Discussion about activity (procedure)

SNOMEDCT

223415003

Recommendation regarding activity (procedure)

SNOMEDCT

566927011

Referral for further care (procedure)

SNOMEDCT

283512014

Referral for further care

SNOMEDCT

183444007

Referral for further care (procedure)

SNOMEDCT

709318013

Provision of specialist further education (procedure)

SNOMEDCT

456380014

Provision of specialist further education

SNOMEDCT

706904013

Further opinion sought (finding)

SNOMEDCT

453917017

Further opinion sought

SNOMEDCT

223415003

Recommendation regarding activity (procedure)

SNOMEDCT

223440005

Recommendation to undertake activity (procedure)

SNOMEDCT

223469001

Discussion about activity (procedure)

SNOMEDCT

390893007

Referral to physical activity program (procedure)

SNOMEDCT

410289001

Exercises education, guidance, and counseling (procedure)

SNOMEDCT

223415003

Recommendation regarding activity (procedure)

SNOMEDCT

762227003

Provision of advice about aerobic exercise (procedure)

SNOMEDCT

710138000

Promotion of adherence to exercise regime (procedure)

SNOMEDCT

410335001

Exercises case management (procedure)

SNOMEDCT

410289001

Exercises education, guidance, and counseling (procedure)

SNOMEDCT

386292004

Exercise promotion: stretching (procedure)

SNOMEDCT

386291006

Exercise promotion: strength training (procedure)

SNOMEDCT

370873006

Ambulation therapy management (procedure)

SNOMEDCT

370872001

Ambulation therapy education (procedure)

SNOMEDCT

370870009

Ambulation therapy assessment (procedure)

SNOMEDCT

304549008

Giving encouragement to exercise (procedure)

SNOMEDCT

304507003

Exercise education

SNOMEDCT

308477009

Referral to psychiatrist (procedure)

SNOMEDCT

703978000

Referral to primary care service (procedure)

SNOMEDCT

183851006

Referral to clinic (procedure)

SNOMEDCT

81294000

Patient referral for psychotherapy (procedure)

SNOMEDCT

88848003

Psychiatric follow-up (procedure)

SNOMEDCT

309627007

Child referral - clinical psychologist (procedure)

SNOMEDCT

444831000124102

Referral for physical therapy (procedure)

SNOMEDCT

444911000124101

Referral for office-based physical therapy (procedure)

SNOMEDCT

416790000

Referral for home physical therapy (procedure)

SNOMEDCT

750281000124115

Referral for occupational therapy (procedure)

SNOMEDCT

750291000124117

Referral for occupational therapy

SNOMEDCT

702543017

Referral to occupational therapy service (procedure)

SNOMEDCT

449079012

Referral to occupational therapy service

SNOMEDCT

2788042017

Referral to pediatric occupational therapy service (procedure)

SNOMEDCT

2792715016

Referral to pediatric occupational therapy service

SNOMEDCT

2792714017

Referral to paediatric occupational therapy service

SNOMEDCT

702544011

Referral to community-based occupational therapy service (procedure)

SNOMEDCT

449080010

Referral to community-based occupational therapy service

SNOMEDCT

449081014

Referral to community occupational therapy service

Presence of key phrases in clinical note may meet numerator follow-up component for Axon Registry.

Suggested key phrases to locate follow-up via Axon Registry

are included below. This list is not exhaustive and will

be updated annually if adopted into the Axon Registry:

• “Behavioral modification”

• “Treatment plan updated”

• “Treatment changed”

• “Lifestyle changes”

• “Referral to physical therapy”

• “Referral to occupational therapy”

• “Referral to exercise program”

• “Referral to sleep study”

• “Referral to polysomnography”

• “Further testing conducted”

• “Additional tests ordered”

• “Pharmacological updates made”

• “Medication adjusted”

Allowable Exclusions

SNOMEDCT

746791000124111

Recommendation refused by patient (situation)

SNOMEDCT

746801000124112

Recommendation refused by patient

SNOMEDCT

2608177018

Refused procedure - after thought (situation)

SNOMEDCT

284171012

Refused procedure - after thought

SNOMEDCT

183947005

Refused procedure - after thought (situation)

SNOMEDCT

2606319010

Refusal of treatment by patient (situation)

SNOMEDCT

169559019

Refusal of treatment by patient

SNOMEDCT

105480006

Refusal of treatment by patient (situation)

SNOMEDCT

2612741019

Refusal of treatment by parents (situation)

SNOMEDCT

1209841012

Refusal of treatment by parents

SNOMEDCT

2608092019

Refused procedure - parent's wish (situation)

SNOMEDCT

284172017

Refused procedure - parent's wish

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

183944003

Procedure refused (situation)

SNOMEDCT

183945002

Procedure refused for religious reason (situation)

SNOMEDCT

413310006

Patient non-compliant - refused access to services (situation)

SNOMEDCT

413311005

Patient non-compliant - refused intervention / support (situation)

SNOMEDCT

413312003

Patient non-compliant - refused service (situation)

SNOMEDCT

183948000

Refused procedure - parent's wish (situation)

SNOMEDCT

416432009

Procedure not wanted (situation)

SNOMEDCT

443390004

Refused (qualifier value)

Presence of key phrases in clinical note may meet allowable exclusion for Axon Registry.

Suggested key phrases to locate allowable exclusions via Axon Registry

are included below. This list is not

exhaustive and will be updated annually if adopted into the Axon Registry:

• “Patient unable to complete a fatigue screening”

• “Patient declines to complete a fatigue screening”

Yes

Flow Chart Diagram: Fatigue Screening and Follow-Up for Patients with MS

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

Was patient screened for fatigue in past 12

months, and if screening positive were provided

appropriate follow-up?

Patient

INCLUDED in

Denominator

On date of encounter, did patient decline

or refuse fatigue screening?

Remove from

denominator*

*Do not remove/exclude

if patient meets the

numerator

On date of encounter, was patient unable

to complete fatigue screening?

Patient

INCLUDED in

Eligible

Population

Patient NOT

Included in

Eligible

Population

Did the patient have at least one new or

established visit with an eligible provider

during the measurement period?

Did patient have a MS diagnosis on the

date of the visit?

Was patient 18 years or older on the date

of the visit?

Exercise and Appropriate Physical Activity Counseling for Patients with Multiple Sclerosis (MS)

Measure Title

Exercise and Appropriate Physical Activity Counseling for Patients with MS

Description

Percentage of patients with MS who are counseled* on the benefits of exercise and appropriate

physical activity for patients with MS in the past 12 months.

Measurement

Period

January 1, 20xx to December 31, 20xx

Eligible

Population

Eligible Providers

Medical Doctor (MD), Doctor of Osteopathy (DO), Clinical Psychologist

(PhD & PsyD), Physician Assistant (PA), Advanced Practice Registered

Nurse (APRN), Physical Therapy (PT), Occupational Therapy (OT)

Care Setting(s)

Outpatient Care

Ages

Any

Event

Office or telehealth encounter

Diagnosis

Multiple Sclerosis

Denominator

Patients with a diagnosis of MS.

Numerator

Patients with MS counseled* on the benefits of exercise and appropriate physical activity for

patients with MS in past 12 months.

*Counseled: to advise seriously and formally after consultation

1-2

Required

Exclusions

None

Allowable

Exclusions

None**

**All patients including those unable to exercise should be provided information on appropriate

range of motion and activity.

Exclusion

Rationale

Not Applicable

Measure Scoring

Percentage

Interpretation of

Score

Higher Score Indicates Better Quality

Measure Type

Process

Level of

Measurement

Provider

Risk Adjustment

Not Applicable

Opportunity to

Improve Gap in

Care

CMS utilized Axon Registry data to establish benchmarks for this measure in 2019. Average

performance for 2019 Axon Registry users reporting on the measure for Merit-based Incentive

Payment System reporting was 73.063%.

Despite known benefits of exercise and physical activity, persons with MS remain inactive.

4-5

The Work Group encourages referral to rehabilitation services, including physical therapy, when

clinically appropriate given the evidence supporting improved outcomes for patients.

6-8

For Process

Measures

Relationship to

Desired Outcome

Increased rates of physical activity and exercise improve the physical functioning levels and

quality of life for patients with MS.

2,9-10

Therefore, healthcare providers should encourage

patients with MS to perform ⩾150 min/week of exercise or lifestyle physical activity.

The following evidence statements are quoted verbatim from the referenced clinical guidelines:

o “Evidence-based treatment interventions for mobility optimization include exercise

promotion (Level 1).”

o “Encourage participation in a regular pattern of exercise to improve mood, fatigue,

quality of life (Level 1).”

2,9,11

o “Encourage people with MS to exercise. Advise them that regular exercise have

beneficial effects on their MS and does not have any harmful effects on their MS.”

2, 9, 12

o “Encourage to perform ⩾150 min/week of exercise and/or lifestyle physical activity”

o "Healthcare providers should endorse & promote the benefits/safety of exercise &

lifestyle physical activity for every person with MS."

o “Ensure all people with MS have a tailored comprehensive review of all aspects of their

care at least once a year.”

Harmonization

with Existing

Measures

There are currently no other comparable measures in national measurement programs or

endorsed by the National Quality Forum.

References

1. Merriam Webster. Available at: http://www.merriam-webster.com/medical/counsel Accessed on

November 13, 2020.

2. Kalb R, Brown T, Coote S, et al. Exercise and lifestyle physical activity recommendations for

people with multiple sclerosis throughout the disease course. Mult Scler. 2020;26(12):1459-

1469.

3. CMS 2020 MIPS Historical Quality Benchmarks. AAN8 Exercise and Appropriate Physical

Activity counseling for Patients with MS. Available at: https://qpp.cms.gov/about/resource-

library Accessed on November 13, 2020.

4. Mayo NE, Bayley M, Duquette P, et. Al. The role of exercise in modifying outcomes for people

with multiple sclerosis: a randomized trial. BMC Neurology. 2013;13:69.

5. Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. Mult

Scler. 2005; 11(4):459-463.

6. Khan F, Turner-Stokes L, Ng L, et al. Multidisciplinary rehabilitation for adults with multiple

sclerosis. Cochrane Database of Systematic Reviews. 2007, Issue 2. Art. No.: CD006036.

7. Rietberg MB, Brooks D, Uitdehaag BMJ, et al. Exercise therapy for multiple sclerosis. Cochrane

Database of Systematic Reviews. 2004, Issue 3. Art. No.: CD003980.

8. Döring A, Caspar FP, Friedemann P, et al. Exercise in multiple sclerosis – an integral component

of disease management. The EPMA Journal. 2012;3:2-13.

9. Mayo C, Miksche K, Atwell-Pope K, et al. The relationship between physical activity and

symptoms of fatigue, mood, and perceived cognitive impairment in adults with multiple

sclerosis. J Clin Exp Neuropsychol. 2019 Sep;41(7):715-722.

10. American College of Sports Medicine: ACSM’s Resource Manual for Guidelines for Exercise

Testing and Prescription, 6

edition edn. Baltimore, MD: Lippincott Williams & Wilkins; 2010.

11. American Association of Neuroscience Nurses (AANN), Association of Rehabilitation Nurses

(ARN), International Organization of Multiple Sclerosis Nurses (IOMSN). Nursing management

of the patient with multiple sclerosis. Glenview (IL): American Association of Neuroscience

Nurses (AANN); 2011. 49 p.

12. National Clinical Guideline Centre (NICE) (UK). Multiple Sclerosis: Management of Multiple

Sclerosis in Primary and Secondary Care. London: National Institute for Health and Care

Excellence; 2014 Oct. 2019 update available at: https://www.nice.org.uk/guidance/cg186

Accessed on November 13, 2020.

Process

Excercise and

appropriate

physical activity

counseling provided

Intermediate

Outcome

Excercise and

physical activity

initiated

Outcome

Improved quality of

life

Reduction of

comorbid

symptoms &

chronic conditions

Code System

Code

Code Description

Initial Population

CPT

99201-99205

Office or other outpatient visit, new patient

CPT

99211-99215

Office or other outpatient visit, established patient

CPT

99241-99245

Office or other outpatient consultation, new or established patient

CPT

97003, 97004

Occupational therapy, evaluation and re-evaluation

CPT

97161-97164

Physical therapy, evaluation and re-evaluation

CPT

96156, 96158,

96164, 96167,

96170

Health and behavior visit

CPT

Telehealth codes TBD

Denominator

ICD-10

G35

Multiple Sclerosis

SNOMEDCT

24700007

Multiple sclerosis (disorder)

SNOMEDCT

192929006

Exacerbation of multiple sclerosis (disorder)

SNOMEDCT

230372003

Acute relapsing multiple sclerosis (disorder)

SNOMEDCT

425500002

Secondary progressive multiple sclerosis (disorder)

SNOMEDCT

426373005

Relapsing remitting multiple sclerosis (disorder)

SNOMEDCT

428700003

Primary progressive multiple sclerosis (disorder)

SNOMEDCT

438511000

Benign multiple sclerosis (disorder)

SNOMEDCT

92926004

Multiple sclerosis of the brainstem (disorder)

SNOMEDCT

192927008

Multiple sclerosis of the spinal cord (disorder)

SNOMEDCT

439567002

Malignant multiple sclerosis (disorder)

SNOMEDCT

724778008

Progressive relapsing multiple sclerosis (disorder)

SNOMEDCT

733028000

Multiple sclerosis, ichthyosis, factor VIII deficiency syndrome (disorder)

SNOMEDCT

766246000

Marburg acute multiple sclerosis (disorder)

SNOMEDCT

816984002

Progressive multiple sclerosis (disorder)

Numerator

SNOMEDCT

281090004

Recommendation to exercise (procedure)

SNOMEDCT

304549008

Giving encouragement to exercise (procedure)

SNOMEDCT

304558001

Reassuring about exercise (procedure)

SNOMEDCT

310882002

Exercise on prescription (regime/therapy)

SNOMEDCT

386291006

Exercise promotion: strength training (procedure)

SNOMEDCT

386292004

Exercise promotion: stretching (procedure)

SNOMEDCT

386463000

Prescribed activity/exercise education (procedure)

SNOMEDCT

390893007

Referral to physical activity program (procedure)

SNOMEDCT

429778002

Patient given written advice on benefits of physical activity (situation)

SNOMEDCT

710138000

Promotion of adherence to exercise regime (procedure)

SNOMEDCT

710883002

Education about increasing activity tolerance (procedure)

SNOMEDCT

410289001

Exercises education, guidance, and counseling (procedure)

SNOMEDCT

304507003

Exercise education (procedure)

SNOMEDCT

762227003

Provision of advice about aerobic exercise (procedure)

SNOMEDCT

819961005

Physical activity guidance (procedure)

SNOMEDCT

435551000124105

Counseling about physical activity (procedure)

SNOMEDCT

183073003

Patient advised about exercise (situation)

SNOMEDCT

386463000

Prescribed activity/exercise education (procedure)

ICD10CM

Z71.89

Exercise counseling

Exclusions

None

Yes

Chart Diagram: Exercise and Appropriate Physical Activity Counseling for Patients with MS

Patient

INCLUDED in

Eligible

Population

Patient NOT

Included in

Eligible

Population

Did the patient have at least one new or

established visit with an eligible provider

during the measurement period?

Patient met

numerator

criteria

Patient did

NOT meet

numerator

criteria

In the past 12 months, was patient counseled on

the benefits of exercise and appropriate physical

activity for patients with MS?

Patient

INCLUDED in

Denominator

Did patient have a MS diagnosis on the date

of the visit?

Contact Information

American Academy of Neurology

201 Chicago Avenue

Minneapolis, MN 55415

[email protected]m

Appendix A: Disclosures

Work Group Member

Disclosures

Lilyana Amezcua, MD, MS, FAAN

Reports active research support from the National MS Society,

NIH NINDS, Bristol Myers Squibb Foundation, and Biogen Idec.;

has served as a consultant to Biogen Idec, Novartis, Alexion

Pharmaceuticals, Genentech, EMD Serono and AbbVie; has

served as primary investigator for clinical trials with MedDay,

Genenetch and PCORI.

Tracie Caller, MD

(non-voting member)

Reports no relevant disclosures for this project.

Jeffrey English, MD

Reports serving as a Board of Directors for the Consortium of

Multiple Sclerosis Centers; has served as consultant to Biogen-

Idec, Novartis, Sanofi-Genzyme, Genetech, EMD-Serono, Teva,

Raptor, Abbvie; served as speaker consultant for the MS

Association of America and National MS Society; is a founding

member of Healthcare Impact Partners and HIP Nation.

Neeta Garg, MD

Reports no disclosures.

Barbara Giesser, MD, FAAN

Reports royalties from 2 multiple sclerosis publications and has

received a consulting fee from Greenwich Biosciences.

Adam G. Kelly, MD, FAAN

(non-voting member)

Reports no relevant disclosures for this project.

Iris Vanessa Marin Collazo, MD

Reports no relevant disclosures for this project.

Amanda Montague, EdM

Reports no disclosures.

Michael Olek, DO

Reports no disclosures.

Elizabeth Page

Reports no disclosures.

Alex Rae-Grant, MD, FRCPC, FAAN

(Chair)

Reports currently serving as neurology editor for DynaMed a

subscription based point of care tool for clinicians with no

industry support or advertising; royalties from 2 textbooks he has

published, 1 on neurology and 1 on multiple sclerosis; organizes

neurology review courses.