CMS 139 Falls: Screening for Future Fall Risk
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Click the following dropdown to see what's new for this measure in 2020.
What's New in 2020
The CMS 139 Falls: Screening for Future Fall Risk measure has been updated for 2020 reporting in PSR v2020.3. Here's a summary of what's changed since the 2019 reporting logic was released in PSR 2019.
All CMS measures in PSR v2020.3 use logic described in the following help topic: Identifying Event Times. Some of this logic was revised for version PSR 2020.2.
Measure Specification and Value Sets Changes
For the 2020 reporting year, the detailed measure help for this measure includes hyperlinks to the Value Sets used by this measure. You must be registered for a UMLS license and signed in to your account to see this content.
Overview
This measure reports the percentage of patients 65 years old or older who had their risk of future falls assessed during the measurement period.
At a Glance
| eMeasure ID | CMS139v8 |
| NQF | N/A |
| Used For? | Medicaid PI/Stage 3, MIPS (Quality) |
| Domain | Patient Safety |
| MIPS Quality ID | 318 |
| MIPS Measure Type | Process |
| MIPS High Priority? | Yes |
Measure Specification and Value Sets
You should be familiar with this measure’s specification, Value Sets, and direct reference codes (if applicable). Refer to
Identifying Event Times
See Identifying Event Times for important information about the logic this dashboard uses.
Amending Signed Notes
As a best practice, Notes should not be signed until they are finalized. Amending a signed Note (by making changes to it in Prime Suite and then re-saving it) will change a patient’s qualification for this measure. Re-signing the amended Note may allow the patient to qualify again, but only if it is re-signed during the time period required by the measure.
Measure Calculations
| Initial Population | Patients aged 65 years and older with a visit during the measurement period. |
| Denominator | Initial Patient Population |
| Numerator | Patients who were screened for future fall risk at least once within the measurement period |
Measure Details
Initial Population/Denominator
Patients are counted in the denominator if they meet both of the following:
| 1. | They were 65 years old or older at the beginning of the measurement period. Age is based on the date of birth (DOB) entered on the Information page. |
| 2. | They had at least one non-voided face-to-face encounter during the measurement period. This must be documented in the Plan or E&M section of a Note using a code from one of the following Value Sets: |
- Annual Wellness Visit
- Audiology Visit
- Care Services in Long-Term Residential Facility
- Discharge Services - Nursing Facility
- Home Healthcare Services
- Nursing Facility Visit
- Office Visit
- Ophthalmological Services
- Preventive Care Services – Established Office Visit, 18 and Up
- Preventive Care Services-Individual Counseling
- Preventive Care Services-Initial Office Visit, 18 and Up
Denominator Exclusions
Patients will be excluded from the denominator if they meet any of the following. Select a link for additional information.
- They received hospice care.
- They were determined to be non-ambulatory.
Hospice Care
Patients will be excluded from the denominator if they received hospice care. This must be documented with a vocabulary term in the Results or in a Flowsheet. This documentation must show one of the following:
- They were discharged from the hospital into hospice care during the measurement period. This must be documented with a vocabulary term using a parent code from the Encounter Inpatient Value Set and a child code using either of the following SNOMEDCT version 2019-05-10 direct reference codes:
- 428371000124100, indicating a patient was Discharged to a health care facility for hospice care.
- 428361000124107, indicating a patient was Discharged to home for hospice care.
- They received hospice care. This must be documented with a vocabulary term in a Flowsheet using a code from the Hospice care ambulatory Value Set. The date the provider enters this documentation must occur during the measurement period.
- They had an order for hospice care. This must be documented in the Plan or Results section of a Note using a code from the Hospice care ambulatory Value Set. This order must have been created during the measurement period.
Determined to be Non-Ambulatory
Patients will be excluded from the denominator if they were determined to be non-ambulatory. This can be indicated by either of the following:
- They were determined to be non-ambulatory during the measurement period. This must be documented with a vocabulary term in the Results or a Flowsheet using a parent code from the Ambulatory Status Value Set and a child code from the Patient not ambulatory Value Set. This documentation must be created during the measurement period.
- They were determined to be non-ambulatory prior to the beginning of the measurement period. This must be documented with a vocabulary term in the Results or a Flowsheet using a parent code from the Ambulatory Status Value Set and a child code from the Patient not ambulatory Value Set. Note that if the patient had more than one ambulatory status prior the measurement period, the last ambulatory status prior to the measurement period is used to determine if they were non-ambulatory. If the patient was non-ambulatory before the measurement period and was then determined to be ambulatory during the measurement period, they will no longer qualify for this exclusion. An ambulatory status will be documented with a vocabulary term in the Results or a Flowsheet using a parent code from the Ambulatory Status Value Set.
Numerator
Patients are counted in the numerator if they had their risk of future falls assessed during the measurement period. This must be documented using a code from the Falls Screening Value Set. This must be documented as a vocabulary term in the Results or in a Flowsheet.
Numerator Exclusions
Not applicable
Denominator Exception
None
