Quality Documentation Tips

Augusta Care Partners just wrapped up our 2017 Medicare quality reporting project, and we are very pleased with our preliminary results. Thanks to all of our providers for working so hard on the quality measures. Of course, there is always room for improvement! Here are a couple of quick documentation tips that will help you meet the quality measure requirements in 2018:

BMI Screening & Follow-Up

This is two-step measure. First, document a BMI within 6 months of the most recent outpatient visit. Second, if the BMI is outside of the CMS norm (18.5-25) document teaching on healthy diet and exercise. The good news is that for 2018 the diet and exercise instruction can be done within the last 12 months of the most recent visit. In 2017 and previous years, this was required within 6 months. This CMS change should help our performance in 2018.

Blood Pressure Control (<140/90 in patients with the diagnosis of hypertension)

This looks at the most recent outpatient blood pressure in the measurement period. Consider retaking the blood pressure at the end of the visit, when it is elevated initially. If the blood pressure remains above target, consider having the patient simply return in 1-2 weeks for the nurse to recheck it. If you have decided on a different BP goal for safety or other reasons, document it and your reasoning.

Flu Vaccine

Remember to document when a patient refuses the flu vaccine. This must be done each flu season.