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Measure DevelopmentACO #9 – Prevention Quality Indicator (PQI): Ambulatory Care SensitiveConditions: Admissions for Chronic Obstructive Pulmonary Disease (COPD) orAsthma in Older AdultsMeasure Information Form (MIF)Data Source Medicare Part B Carrier Claims Medicare Outpatient Claims Medicare Inpatient Claims Medicare beneficiary enrollment dataMeasure Set ID ACO #9Version Number and Effective Date Version 2.1, effective 1/1/15CMS Approval Date 11/19/14NQF ID #275, adapted for quality measurement in Medicare Accountable Care OrganizationsDate Endorsed N/ACare Setting HospitalsUnit of Measurement Accountable Care Organization (ACO)Measurement Duration Calendar YearMeasurement Period Calendar YearMeasure Type OutcomeA Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 1
Measure DevelopmentMeasure Scoring Prevention quality indicator (PQI) score, that is a ratio of observed admissions to expected admissions for ChronicObstructive Pulmonary Disease (COPD) or AsthmaPayer Source Medicare Fee-for-ServiceImprovement Notation Lower PQI scores are betterMeasure StewardAgency for Healthcare Research and Quality (AHRQ) with adaptations by Centers for Medicare and Medicaid Services (CMS)(co-stewards).Copyright / Disclaimer This Medicare ACO PQI COPD/Asthma quality measure is adapted from the general population PQI quality measurefor COPD/Asthma that is developed by AHRQ (AHRQ, 2013).Measure description All discharges with an ICD-9 or ICD-10 principal diagnosis code for COPD or Asthma in adults ages 40 years andolder, for ACO assigned (SSP) or aligned (Pioneer) Medicare beneficiaries with COPD or Asthma, with risk-adjustedcomparison of observed discharges to expected discharges for each ACO.RationaleHospital admissions for COPD or asthma are a Prevention Quality Indicator of interest to comprehensive health caredelivery systems including ACOs. COPD or Asthma can often be controlled in an outpatient setting. Evidence suggests thatthese hospital admissions could have been avoided through high quality outpatient care, or the condition would have beenless severe if treated early and appropriately. Proper outpatient treatment and adherence to care may reduce the rate ofoccurrence for this event, and thus of hospital admissions.Clinical Recommendation StatementBindman et al. (1995) reported that self-reported access to care explained 27 percent of the variation in COPDhospitalization rates at the ZIP code cluster level. Millman (1993) found that low-income ZIP codes had 5.8 times moreCOPD hospitalizations per capita than high-income ZIP codes. Physician adherence to practice guidelines and patientcompliance also influence the effectiveness of therapy. Practice guidelines for COPD have been developed and publishedover the last decade (Hackner, 1999). With appropriate outpatient treatment and compliance, hospitalizations for theexacerbations of COPD and decline in lung function should be minimized.Based on empirical results, areas with high rates of COPD admissions also tend to have high rates of admissions for otherAmbulatory Care Sensitive Conditions. The signal ratio (i.e., the proportion of the total variation across areas that is trulyrelated to systematic differences in area performance rather than random variation) is very high, at 93.4 percent, indicatingthat the differences in age-sex adjusted rates likely represent true differences across areas (AHRQ, 2007).Risk adjustment for age and sex exerts strongest influence in areas with highest admission rates. As a PQI, admissions forchronic obstructive pulmonary disease are not a measure of hospital quality, but rather one measure of the quality ofambulatory care.A Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 2
Measure DevelopmentReferencesAHRQ. Guide to Prevention Quality Indicators. Rockville, Maryland: U.S. Agency for Healthcare Research and Quality,2007.Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA 1995;274(4):30511.Hackner D, Tu G, Weingarten S, et al. Guidelines in pulmonary medicine: a 25-year profile. Chest 1999; 116(4):1046-62.Millman M, editor. Committee on Monitoring Access to Personal Health Care Services. Washington, DC: National AcademyPress; 1993.Release Notes / Summary of Changes There have been no substantial changes made to the measure specifications. The specifications reflect the mostrecent version (version 4.5, May 2013) of the technical specifications posted on the AHRQ website for PQI #8. Updated the measure specifications to incorporate ICD-10 diagnosis and procedure codes in preparation for theOctober 2015 ICD-10 transitions.Technical Specifications Target Population: ACO assigned or aligned Medicare beneficiariesDenominator Denominator StatementExpected (risk adjusted) discharges from an acute care or critical access hospital with a principal diagnosis of COPDor Asthma, for Medicare FFS beneficiaries assigned or aligned to an ACO, aged 40 years and older, with COPD orAsthma Denominator DetailsThe ICD-9 or ICD-10 codes used to identify Medicare beneficiaries with COPD or Asthma for this Medicare ACO PQIquality measure are as follows:ICD-9 CodeDescriptionICD-10 Code491.0Simple chronic bronchitisJ41.0491.1Mucopurulent chronic bronchitisJ41.1491.20Obstructive chronic bronchitis without exacerbationJ41.8Obstructive chronic bronchitis with (acute)491.21J42.exacerbation491.8Other chronic bronchitisJ43.0491.9492.0492.8494.0Unspecified chronic bronchitisEmphysematous blebOther emphysemaBronchiectasis without acute s with acute exacerbationJ44.0A Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.DescriptionSimple chronic bronchitisMucopurulent chronic bronchitisMixed simple and mucopurulent chronic bronchitisUnspecified chronic bronchitisUnilateral pulmonary emphysema [MacLeod'ssyndrome]Panlobular emphysemaCentrilobular emphysemaOther emphysemaEmphysema, unspecifiedChronic obstructive pulmonary disease with acutelower respiratory infection(continued)Page 3
Measure DevelopmentICD-9 CodeChronic airway obstruction, not elsewhere classifiedJ44.1493.00493.01493.02493.10Extrinsic asthma, unspecifiedExtrinsic asthma with status asthmaticusExtrinsic asthma with (acute) exacerbationIntrinsic asthma, 45.32493.11Intrinsic asthma with status asthmaticusJ45.41493.12493.20493.21Intrinsic asthma with (acute) exacerbationChronic obstructive asthma, unspecifiedChronic obstructive asthma with status asthmaticusChronic obstructive asthma with (acute)exacerbationExercise induced bronchospasmCough variant asthmaAsthma, unspecified type, unspecifiedAsthma, unspecified type, with status asthmaticusAsthma, unspecified type, with (acute) exacerbationJ45.42J45.51J45.52DescriptionChronic obstructive pulmonary disease with (acute)exacerbationChronic obstructive pulmonary disease, unspecifiedBronchiectasis with acute lower respiratory infectionBronchiectasis with (acute) exacerbationBronchiectasis, uncomplicatedMild intermittent asthma with (acute) exacerbationMild intermittent asthma with status asthmaticusMild persistent asthma with (acute) exacerbationMild persistent asthma with status asthmaticusModerate persistent asthma with (acute)exacerbationModerate persistent asthma with status asthmaticusSevere persistent asthma with (acute) exacerbationSevere persistent asthma with status asthmaticusJ45.901Unspecified asthma with (acute) d asthma with status asthmaticusExercise induced bronchospasmCough variant asthmaOther riptionICD-10 CodeThese ICD-9 or ICD-10 codes for COPD or Asthma can be found in any Medicare Outpatient claims, Inpatientclaims, or Part B Carrier claims for the ACO’s assigned or aligned beneficiary in the performance year for thebeneficiary to be included in the denominator.The Medicare ACO PQI quality measure denominator specifications are adapted from the AHRQ PQI specificationswith adjustments to the reference population to focus on Medicare beneficiaries since they are likely to be olderand more disabled than the general population. Additionally, ACOs may have more and varying proportions ofpatients with the chronic conditions targeted by the PQI quality measures (COPD or Asthma for this ACO PQI). As aresult, the changes made to adapt the AHRQ PQIs to the Medicare population for the Medicare ACO PQIs includethe following:1.2.3. Change the PQI denominator to include only Medicare beneficiaries assigned or aligned to a Medicare ACO,instead of the general population in a geographic area (as currently specified for AHRQ PQIs), and allow partyear Medicare beneficiaries to be included in the denominator.Change the PQI denominators to include only those beneficiaries who were diagnosed with the conditionunder consideration (COPD/Asthma) instead of patients of any disease status (as currently specified for AHRQPQIs).Exclude beneficiaries with a diagnosis of ESRD from the denominator populations for. ESRD patients aresignificantly more prone to hospitalization, are severely ill, and are a much larger proportion of Medicarebeneficiaries than they are in the general population. As a result, the PQI measures may not be goodmeasures of quality of care in treatment of Medicare beneficiaries with COPD or Asthma who also have ESRD.Denominator Exceptions and Exclusions1.2.3.Beneficiaries with a diagnosis of ESRDBeneficiaries not eligible for both Medicare Part A and Part BBeneficiaries with missing data for gender, age, or principal diagnosisA Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 4
Measure Development Denominator Exceptions and Exclusions DetailsTo identify beneficiaries for the ESRD exclusion the MS CD variable (CWF Beneficiary Medicare Status Code) isused. Excluded beneficiaries including those with MS CD values equal to 11 (aged with ESRD), 21 (disabled withESRD), or 31 (ESRD only).Numerator Numerator StatementObserved discharges from an acute care hospital or critical access hospital with a principal diagnosis of ChronicObstructive Pulmonary Disease or Asthma, for Medicare beneficiaries in the denominator population for thismeasure. Numerator DetailsThe ICD-9 and ICD-10 codes used to identify hospital discharges with a principal diagnosis of COPD or Asthma forthis Medicare ACO PQI quality measure are as follows:1.An ICD-9 or ICD-10 principal diagnosis code that indicates COPD (listed in Appendix A)OR2.An ICD-9 or ICD-10 principal diagnosis code that indicates acute bronchitis (listed in Appendix A) AND an ICD-9or ICD-10 secondary diagnosis code that indicates COPD (Listed in Appendix A)OR3.An ICD-9 or ICD-10 principal diagnosis code that indicates asthma (Listed in Appendix A)These ICD-9 or ICD-10 codes for COPD or Asthma can be found for any Medicare Inpatient claims for the ACO’sassigned or aligned beneficiary in the performance year for that discharge to be included in the numerator. Thesum of all of these discharges is calculated for the performance year for all of the assigned or aligned beneficiariesfor each ACO to calculate the numerator. Numerator Exceptions and Exclusions1.2. Transfers to a hospital, Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF), or another health carefacility are excluded from the numeratorDischarges are excluded from the numerator if the admission is associated with a diagnosis of Cystic fibrosis oranomalies of the respiratory systemNumerator Exceptions and Exclusions Details1.2.The AHRQ PQI SAS software excludes admissions that are transfers to a hospital, skilled nursing facility orIntermediate Care Facility, or another healthcare facility, identifying these transfers using HCUP variables SIDASOURCE and POINTOFORIGINUB04 codes. The Medicare claims data available from the IDR does not includethese codes. As a result, the Medicare ACO PQIs use the Medicare claims variable “Source of Admission(SRC ADMS)” to identify transfers. For the Medicare ACO PQIs patients were excluded with an SCR ADMSvalue of 4 (transfer from hospital), 5 (transfer from skilled nursing facility), or 6 (transfer from another healthcare facility). However, previous work with the SCR ADMS variable has found that it is sometimes unreliable.As a result, to better ensure that all transfers were excluded the Medicare ACO PQI software excludesbeneficiaries with two Part A Inpatient claims admissions on the same day at two different facilities.Discharge is excluded from the numerator if the admission is associated with a diagnosis of Cystic fibrosis oranomalies of the respiratory system, as indicated by any of the following ICD-9 or ICD-10 diagnosis codes:A Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 5
Measure DevelopmentICD-9 Code516.69747.21DescriptionCystic fibrosis without mention of meconiumileusCystic fibrosis with meconium ileusCystic fibrosis with pulmonary manifestationsCystic fibrosis with gastrointestinalmanifestationsCystic fibrosis with other manifestationsNeuroendocrine cell hyperplasia of infancyPulmonary interstitial glycogenosisSurfactant mutations of the lungAlveolar capillary dysplasia with veinmisalignmentOther interstitial lung diseases of childhoodAnomalies of aortic arch748.3Other anomalies of larynx, trachea, and bronchusP27.1748.4Congenital cystic lungP27.8748.5Agenesis, hypoplasia, and dysplasia of lungP27.9748.60748.61748.69748.8748.9Anomaly of lung, unspecifiedCongenital bronchiectasisOther congenital anomalies of lungOther specified anomalies of respiratory systemUnspecified anomaly of respiratory systemTracheoesophageal fistula, esophageal atresiaand stenosisSitus inversusChronic respiratory disease arising in theperinatal periodQ25.4Q31.1Q31.2Q31.3Q31.5Other interstitial lung diseases of childhoodWilson-Mikity syndromeBronchopulmonary dysplasia originating in theperinatal periodOther chronic respiratory diseases originating inthe perinatal periodUnspecified chronic respiratory disease originatingin the perinatal periodOther congenital malformations of aortaCongenital subglottic stenosisLaryngeal hypoplasiaLaryngoceleCongenital laryngomalaciaQ31.8Other congenital malformations of larynxQ31.9Congenital malformation of larynx, unspecifiedQ32.0Congenital 33.3Q33.4Q33.5Q33.6Q33.8Q33.9Other congenital malformations of tracheaCongenital bronchomalaciaCongenital stenosis of bronchusOther congenital malformations of bronchusCongenital cystic lungAccessory lobe of lungSequestration of lungAgenesis of lungCongenital bronchiectasisEctopic tissue in lungCongenital hypoplasia and dysplasia of lungOther congenital malformations of lungCongenital malformation of lung, 09516.61516.62516.63516.64750.3759.3770.7A Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.ICD-10 CodeDescriptionE84.0Cystic fibrosis with pulmonary manifestationsE84.11E84.19Meconium ileus in cystic fibrosisCystic fibrosis with other intestinal manifestationsE84.8Cystic fibrosis with other manifestationsE84.9J84.83J84.841J84.842Cystic fibrosis, unspecifiedSurfactant mutations of the lungNeuroendocrine cell hyperplasia of infancyPulmonary interstitial glycogenosisJ84.843Alveolar capillary dysplasia with vein misalignmentJ84.848P27.0Page 6
Measure DevelopmentICD-9 CodeDescriptionICD-10 89.3DescriptionAnomaly of pleuraCongenital cyst of mediastinumOther specified congenital malformations ofrespiratory systemCongenital malformation of respiratory system,unspecifiedAtresia of esophagus without fistulaAtresia of esophagus with tracheo-esophagealfistulaCongenital tracheo-esophageal fistula withoutatresiaCongenital stenosis and stricture of esophagusEsophageal webSitus inversusStratification or Risk AdjustmentThis measure uses risk adjustment and is not stratified.A Medicare claims data 5% file was used for re-estimating the AHRQ COPD/Asthma hospital discharge logistic regressionprediction model used for risk adjustment for this Medicare ACO COPD/Asthma PQI measure. The 5% file is nationallyrepresentative for the Medicare FFS population, and replaced the general population data used for the AHRQ PQI measureprediction models. For this Medicare ACO PQI risk adjustment analysis it was further restricted to Medicare beneficiarieswho met the inclusion criteria for the ACO program and the COPD/Asthma disease diagnosis criteria for the Medicare ACOPQI quality measure denominator. The prediction variables in this model were the age-sex categories identified for theMedicare populations for the ACO PQI quality measures. These models produced coefficients that were included in theACO PQI calculation SAS software as risk adjusters to calculate the expected rate of hospital discharges for an ACOpopulation given its age and sex distribution.For this Medicare ACO PQI prediction model, the AHRQ age ranges used for risk adjustment were revised to reflect ageranges that are more appropriate for the Medicare FFS population. The new age ranges are: 0 to 39, 40 to 65, 65 to 69, 70to 74, 75 to 79, 80 to 84, and 85 . They were used to calculate the age-sex categories used as predictors in the riskadjustment model.Sampling N/ACalculation AlgorithmCalculation of this Medicare ACO COPD/Asthma PQI quality measure includes the following steps:1.2.3.4.Identify the assigned or aligned beneficiaries for each ACO.Apply the eligibility criteria to identify beneficiaries of the correct age, Medicare enrollment status, ESRD status,and satisfying the other eligibility criteria.Search Medicare Part A Inpatient, Outpatient and Part B Carrier claims data to find all of the eligible assigned oraligned beneficiaries with at least one ICD-9 or ICD-10 diagnosis code for COPD or Asthma during the performanceyear for the denominator.Apply the risk adjustment prediction model using the age/sex categories and distribution of the eligible assigned oraligned beneficiaries to calculate the expected number of admissions with a principal diagnosis of COPD or Asthmafor each ACO for the performance year. This constitutes the denominator (i.e., expected rate).A Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 7
Measure Development5.6.Search Medicare Inpatient claims data to find all admissions with a principal diagnosis of COPD or Asthma for thoseeligible assigned or aligned beneficiaries with COPD or Asthma. This constitutes the numerator (i.e., observedrate).Divide the numerator by the denominator to find the Medicare ACO COPD/Asthma PQI score.A Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 8
Measure DevelopmentAppendix A: ICD -9 and ICD-10 Codes to Identify Discharges with a Principal Diagnosis of COPD orAsthmaThe ICD-9 and ICD-10 codes used to identify hospital discharges with a principal diagnosis of COPD or Asthma for thisMedicare ACO PQI quality measure are as follows:1.An ICD-9 or ICD-10 principal diagnosis code that indicates COPDOR2.An ICD-9 or ICD-10 principal diagnosis code that indicates acute bronchitis AND an ICD-9 or ICD-10 secondarydiagnosis code that indicates COPDOR3.1.An ICD-9 or ICD-10 principal diagnosis code that indicates asthmaAn ICD-9 or ICD-10 principal diagnosis code that indicates COPDICD-9 CodeDescription491.0Simple chronic bronchitis491.1Mucopurulent chronic bronchitisObstructive chronic bronchitis without491.20exacerbationObstructive chronic bronchitis with (acute)491.21exacerbationICD-10 CodeDescriptionJ41.0Simple chronic bronchitisJ41.1Mucopurulent chronic bronchitisJ41.8Mixed simple and mucopurulent chronic bronchitisJ42.Unspecified chronic bronchitis491.8Other chronic bronchitisJ43.0491.9492.0492.8494.0Unspecified chronic bronchitisEmphysematous blebOther emphysemaBronchiectasis without acute s with acute exacerbationJ44.0496.Chronic airway obstruction, not eral pulmonary emphysema [MacLeod'ssyndrome]Panlobular emphysemaCentrilobular emphysemaOther emphysemaEmphysema, unspecifiedChronic obstructive pulmonary disease with acutelower respiratory infectionChronic obstructive pulmonary disease with (acute)exacerbationChronic obstructive pulmonary disease, unspecifiedBronchiectasis with acute lower respiratory infectionBronchiectasis with (acute) exacerbationBronchiectasis, uncomplicatedORA Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 9
Measure Development2.An ICD-9 or ICD-10 principal diagnosis code that indicates acute bronchitisICD-9 CodeDescription466.0Acute bronchitis490.Bronchitis, not specified as acute or chronicICD-10 20.9J40.DescriptionAcute bronchitis due to Mycoplasma pneumoniaeAcute bronchitis due to Hemophilus influenzaeAcute bronchitis due to streptococcusAcute bronchitis due to coxsackievirusAcute bronchitis due to parainfluenza virusAcute bronchitis due to respiratory syncytial virusAcute bronchitis due to rhinovirusAcute bronchitis due to echovirusAcute bronchitis due to other specified organismsAcute bronchitis, unspecifiedBronchitis, not specified as acute or chronicANDAn ICD-9 or ICD-10 principal diagnosis code that indicates COPDICD-9 CodeDescription491.0Simple chronic bronchitis491.1Mucopurulent chronic bronchitisObstructive chronic bronchitis without491.20exacerbationObstructive chronic bronchitis with (acute)491.21exacerbationICD-10 CodeDescriptionJ41.0Simple chronic bronchitisJ41.1Mucopurulent chronic bronchitisJ41.8Mixed simple and mucopurulent chronic bronchitisJ42.Unspecified chronic bronchitis491.8Other chronic bronchitisJ43.0491.9492.0492.8494.0Unspecified chronic bronchitisEmphysematous blebOther emphysemaBronchiectasis without acute s with acute exacerbationJ44.0496.Chronic airway obstruction, not eral pulmonary emphysema [MacLeod'ssyndrome]Panlobular emphysemaCentrilobular emphysemaOther emphysemaEmphysema, unspecifiedChronic obstructive pulmonary disease with acutelower respiratory infectionChronic obstructive pulmonary disease with (acute)exacerbationChronic obstructive pulmonary disease, unspecifiedBronchiectasis with acute lower respiratory infectionBronchiectasis with (acute) exacerbationBronchiectasis, uncomplicatedORA Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.Page 10
Measure Development3.An ICD-9-CM principal diagnosis code that indicates asthmaICD-9 Code493.00493.01493.02493.10493.11Intrinsic asthma with status asthmaticusJ45.41493.12493.20Intrinsic asthma with (acute) exacerbationChronic obstructive asthma, unspecifiedChronic obstructive asthma with statusasthmaticusChronic obstructive asthma with (acute)exacerbationExercise induced bronchospasmCough variant asthmaAsthma, unspecified type, unspecifiedAsthma, unspecified type, with status asthmaticusAsthma, unspecified type, with (acute)exacerbationJ45.42J45.51DescriptionMild intermittent asthma with (acute) exacerbationMild intermittent asthma with status asthmaticusMild persistent asthma with (acute) exacerbationMild persistent asthma with status asthmaticusModerate persistent asthma with (acute)exacerbationModerate persistent asthma with status asthmaticusSevere persistent asthma with (acute) exacerbationJ45.52Severe persistent asthma with status asthmaticusJ45.901Unspecified asthma with (acute) d asthma with status asthmaticusExercise induced bronchospasmCough variant asthmaOther scriptionExtrinsic asthma, unspecifiedExtrinsic asthma with status asthmaticusExtrinsic asthma with (acute) exacerbationIntrinsic asthma, unspecifiedA Blueprint for the CMS Measures Management System, Version 9Health Services Advisory Group, Inc.ICD-10 CodeJ45.21J45.22J45.31J45.32Page 11
3. An ICD-9 or ICD-10 principal diagnosis code that indicates asthma (Listed in Appendix A) These ICD-9 or ICD-10 codes for COPD or Asthma can be found for any Medicare Inpatient claims for the ACO's assigned or aligned beneficiary in the performance year for that discharge to be included in the numerator. The
