G-Codes
G8000–G8999: Procedures and Professional Services (Temporary)
G8000–G8999
- G8126Patient with a diagnosis of major depression documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase
- G8127Patient with a diagnosis of major depression not documented as being treated with antidepressant medication during the entire 84 day (12 week) acute treatment phase
- G8128Clinician documented that patient was not an eligible candidate for antidepressant medication during the entire 12 week acute treatment phase measure
- G8395Left ventricular ejection fraction (lvef) >= 40% or documentation as normal or mildly depressed left ventricular systolic function
- G8396Left ventricular ejection fraction (lvef) not performed or documented
- G8397Dilated macular or fundus exam performed, including documentation of the presence or absence of macular edema and level of severity of retinopathy
- G8398Dilated macular or fundus exam not performed
- G8399Patient with documented results of a central dual-energy x-ray absorptiometry (dxa) ever being performed
- G8400Patient with central dual-energy x-ray absorptiometry (dxa) results not documented, reason not given
- G8401Clinician documented that patient was not an eligible candidate for screening
- G8404Lower extremity neurological exam performed and documented
- G8405Lower extremity neurological exam not performed
- G8406Clinician documented that patient was not an eligible candidate for lower extremity neurological exam measure
- G8410Footwear evaluation performed and documented
- G8415Footwear evaluation was not performed
- G8416Clinician documented that patient was not an eligible candidate for footwear evaluation measure
- G8417Bmi is documented above normal parameters and a follow-up plan is documented
- G8418Bmi is documented below normal parameters and a follow-up plan is documented
- G8419Bmi documented outside normal parameters, no follow-up plan documented, no reason given
- G8420Bmi is documented within normal parameters and no follow-up plan is required
- G8421Bmi not documented and no reason is given
- G8422Bmi not documented, documentation the patient is not eligible for bmi calculation
- G8427Eligible clinician attests to documenting in the medical record they obtained, updated, or reviewed the patient's current medications
- G8428Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given
- G8430Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient's current medications list (e.g., patient is in an acute health crisis where time is of the essence and delay of treatment would jeopardize the patient's health status)
- G8431Screening for depression is documented as being positive and a follow-up plan is documented
- G8432Depression screening not documented, reason not given
- G8433Screening for depression not completed, documented patient or medical reason
- G8442Pain assessment not documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool at the time of the encounter
- G8450Beta-blocker therapy prescribed
- G8451Beta-blocker therapy for lvef <=40% not prescribed for reasons documented by the clinician (e.g., low blood pressure, fluid overload, asthma, patients recently treated with an intravenous positive inotropic agent, allergy, intolerance, other medical reasons, patient declined, other patient reasons)
- G8452Beta-blocker therapy not prescribed
- G8458Clinician documented that patient is not an eligible candidate for genotype testing; patient not receiving antiviral treatment for hepatitis c during the measurement period (e.g. genotype test done prior to the reporting period, patient declines, patient not a candidate for antiviral treatment)
- G8460Clinician documented that patient is not an eligible candidate for quantitative rna testing at week 12; patient not receiving antiviral treatment for hepatitis c
- G8461Patient receiving antiviral treatment for hepatitis c during the measurement period
- G8464Clinician documented that prostate cancer patient is not an eligible candidate for adjuvant hormonal therapy; low or intermediate risk of recurrence or risk of recurrence not determined
- G8465High or very high risk of recurrence of prostate cancer
- G8473Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy prescribed
- G8474Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy not prescribed for reasons documented by the clinician (e.g., allergy, intolerance, pregnancy, renal failure due to ace inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (e.g., patient declined, other patient reasons)
- G8475Angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy not prescribed, reason not given
- G8476Most recent blood pressure has a systolic measurement of < 140 mmhg and a diastolic measurement of < 90 mmhg
- G8477Most recent blood pressure has a systolic measurement of >= 140 mmhg and/or a diastolic measurement of >= 90 mmhg
- G8478Blood pressure measurement not performed or documented, reason not given
- G8482Influenza immunization administered or previously received
- G8483Influenza immunization was not administered for reasons documented by clinician (e.g., patient allergy or other medical reasons, patient declined or other patient reasons, vaccine not available or other system reasons)
- G8484Influenza immunization was not administered, reason not given
- G8485I intend to report the diabetes mellitus (dm) measures group
- G8486I intend to report the preventive care measures group
- G8487I intend to report the chronic kidney disease (ckd) measures group
- G8489I intend to report the coronary artery disease (cad) measures group
- G8490I intend to report the rheumatoid arthritis (ra) measures group
- G8491I intend to report the hiv/aids measures group
- G8492I intend to report the perioperative care measures group
- G8493I intend to report the back pain measures group
- G8494All quality actions for the applicable measures in the diabetes mellitus (dm) measures group have been performed for this patient
- G8495All quality actions for the applicable measures in the chronic kidney disease (ckd) measures group have been performed for this patient
- G8496All quality actions for the applicable measures in the preventive care measures group have been performed for this patient
- G8497All quality actions for the applicable measures in the coronary artery bypass graft (cabg) measures group have been performed for this patient
- G8498All quality actions for the applicable measures in the coronary artery disease (cad) measures group have been performed for this patient
- G8499All quality actions for the applicable measures in the rheumatoid arthritis (ra) measures group have been performed for this patient
- G8500All quality actions for the applicable measures in the hiv/aids measures group have been performed for this patient
- G8501All quality actions for the applicable measures in the perioperative care measures group have been performed for this patient
- G8502All quality actions for the applicable measures in the back pain measures group have been performed for this patient
- G8506Patient receiving angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy
- G8509Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given
- G8510Screening for depression is documented as negative, a follow-up plan is not required
- G8511Screening for depression documented as positive, follow-up plan not documented, reason not given
- G8530Autogenous av fistula received
- G8531Clinician documented that patient was not an eligible candidate for autogenous av fistula
- G8532Clinician documented that patient received vascular access other than autogenous av fistula, reason not given
- G8535Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter related to one of the following reasons: (1) patient refuses to participate in the screening and has reasonable decisional capacity for self-protection, or (2) patient is in an urgent or emergent situation where time is of the essence and to delay treatment to perform the screening would jeopardize the patient's health status
- G8536No documentation of an elder maltreatment screen, reason not given
- G8539Functional outcome assessment documented as positive using a standardized tool and a care plan based on identified deficiencies is documented within two days of the functional outcome assessment
- G8540Functional outcome assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool at the time of the encounter
- G8541Functional outcome assessment using a standardized tool not documented, reason not given
- G8542Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required
- G8543Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented within two days of assessment, reason not given
- G8544I intend to report the coronary artery bypass graft (cabg) measures group
- G8545I intend to report the hepatitis c measures group
- G8547I intend to report the ischemic vascular disease (ivd) measures group
- G8548I intend to report the heart failure (hf) measures group
- G8549All quality actions for the applicable measures in the hepatitis c measures group have been performed for this patient
- G8551All quality actions for the applicable measures in the heart failure (hf) measures group have been performed for this patient
- G8552All quality actions for the applicable measures in the ischemic vascular disease (ivd) measures group have been performed for this patient
- G8559Patient referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation
- G8560Patient has a history of active drainage from the ear within the previous 90 days
- G8561Patient is not eligible for the referral for otologic evaluation for patients with a history of active drainage measure
- G8562Patient does not have a history of active drainage from the ear within the previous 90 days
- G8563Patient not referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not given
- G8564Patient was referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not specified)
- G8565Verification and documentation of sudden or rapidly progressive hearing loss
- G8566Patient is not eligible for the "referral for otologic evaluation for sudden or rapidly progressive hearing loss" measure
- G8567Patient does not have verification and documentation of sudden or rapidly progressive hearing loss
- G8568Patient was not referred to a physician (preferably a physician with training in disorders of the ear) for an otologic evaluation, reason not given
- G8569Prolonged postoperative intubation (> 24 hrs) required
- G8570Prolonged postoperative intubation (> 24 hrs) not required
- G8571Development of deep sternal wound infection/mediastinitis within 30 days postoperatively
- G8572No deep sternal wound infection/mediastinitis
- G8573Stroke following isolated cabg surgery
- G8574No stroke following isolated cabg surgery
- G8575Developed postoperative renal failure or required dialysis
- G8576No postoperative renal failure/dialysis not required
- G8577Re-exploration required due to mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native, vessel, graft, or both), valve dysfunction, aortic reintervention, or other cardiac reason
- G8578Re-exploration not required due to mediastinal bleeding with or without tamponade, unplanned coronary artery intervention (native, vessel, graft, or both), valve dysfunction, aortic reintervention, or other cardiac reason
- G8579Antiplatelet medication at discharge
- G8580Antiplatelet medication contraindicated
- G8581No antiplatelet medication at discharge
- G8582Beta-blocker at discharge
- G8583Beta-blocker contraindicated
- G8584No beta-blocker at discharge
- G8585Anti-lipid treatment at discharge
- G8586Anti-lipid treatment contraindicated
- G8587No anti-lipid treatment at discharge
- G8593Lipid profile results documented and reviewed (must include total cholesterol, hdl-c, triglycerides and calculated ldl-c)
- G8594Lipid profile not performed, reason not given
- G8595Most recent ldl-c < 100 mg/dl
- G8597Most recent ldl-c >= 100 mg/dl
- G8598Aspirin or another antiplatelet therapy used
- G8599Aspirin or another antiplatelet therapy not used, reason not given
- G8600Iv thrombolytic therapy initiated within 4.5 hours (<= 270 minutes) of time last known well
- G8601Iv thrombolytic therapy not initiated within 4.5 hours (<= 270 minutes) of time last known well for reasons documented by clinician (e.g. patient enrolled in clinical trial for stroke, patient admitted for elective carotid intervention)
- G8602Iv thrombolytic therapy not initiated within 4.5 hours (<= 270 minutes) of time last known well, reason not given
- G8627Surgical procedure performed within 30 days following cataract surgery for major complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong power iol, retinal detachment, or wound dehiscence)
- G8628Surgical procedure not performed within 30 days following cataract surgery for major complications (e.g., retained nuclear fragments, endophthalmitis, dislocated or wrong power iol, retinal detachment, or wound dehiscence)
- G8629Documentation of order for prophylactic parenteral antibiotic to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)
- G8630Documentation that administration of prophylactic parenteral antibiotics was initiated within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required), as ordered
- G8631Clinician documented that patient was not an eligible candidate for ordering prophylactic parenteral antibiotics to be given within one hour (if fluoroquinolone or vancomycin, two hours) prior to surgical incision (or start of procedure when no incision is required)
- G8632Prophylactic parenteral antibiotics were not ordered to be given or given within one hour (if fluoroquinolone or vancomycin, two hours) prior to the surgical incision (or start of procedure when no incision is required), reason not given
- G8633Pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed
- G8634Clinician documented patient not an eligible candidate to receive pharmacologic therapy for osteoporosis
- G8635Pharmacologic therapy for osteoporosis was not prescribed, reason not given
- G8645I intend to report the asthma measures group
- G8646All quality actions for the applicable measures in the asthma measures group have been performed for this patient
- G8647Residual score for the knee impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)
- G8648Residual score for the knee impairment successfully calculated and the score was less than zero (< 0)
- G8649Risk-adjusted functional status change residual score for the knee impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8650Residual score for the knee impairment not measured because the patient did not complete the lepf prom at initial evaluation and/or near discharge, reason not given
- G8651Residual score for the hip impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)
- G8652Residual score for the hip impairment successfully calculated and the score was less than zero (< 0)
- G8653Risk-adjusted functional status change residual scores for the hip impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8654Residual score for the hip impairment not measured because the patient did not complete the lepf prom at initial evaluation and/or near discharge, reason not given
- G8655Residual score for the lower leg, foot or ankle impairment successfully calculated and the score was equal to zero (0) or greater than zero ( > 0)
- G8656Residual score for the lower leg, foot or ankle impairment successfully calculated and the score was less than zero (< 0)
- G8657Risk-adjusted functional status change residual score for the lower leg, foot or ankle impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8658Residual score for the lower leg, foot or ankle impairment not measured because the patient did not complete the lepf prom at initial evaluation and/or near discharge, reason not given
- G8659Residual score for the low back impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)
- G8660Residual score for the low back impairment successfully calculated and the score was less than zero (< 0)
- G8661Risk-adjusted functional status change residual score for the low back impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8662Residual score for the low back impairment not measured because the patient did not complete the low back fs prom at initial evaluation and/or near discharge, reason not given
- G8663Residual score for the shoulder impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)
- G8664Residual score for the shoulder impairment successfully calculated and the score was less than zero (< 0)
- G8665Risk-adjusted functional status change residual score for the shoulder impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8666Residual score for the shoulder impairment not measured because the patient did not complete the shoulder fs prom at initial evaluation and/or near discharge, reason not given
- G8667Residual score for the elbow, wrist or hand impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)
- G8668Residual score for the elbow, wrist or hand impairment successfully calculated and the score was less than zero (< 0)
- G8669Risk-adjusted functional status change residual score for the elbow, wrist or hand impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8670Residual score for the elbow, wrist or hand impairment not measured because the patient did not complete the elbow/wrist/hand fs prom at initial evaluation and/or near discharge, reason not given
- G8671Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0)
- G8672Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment successfully calculated and the score was less than zero (< 0)
- G8673Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment not measured because the patient did not complete the fs status survey near discharge, patient not appropriate
- G8674Risk-adjusted functional status change residual score for the neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment not measured because the patient did not complete the general orthopedic fs prom at initial evaluation and/or near discharge, reason not given
- G8682Lvf testing documented as being performed prior to discharge or in the previous 12 months
- G8683Lvf testing not performed prior to discharge or in the previous 12 months for a medical or patient documented reason
- G8685Lvf testing not documented as being performed prior to discharge or in the previous 12 months, reason not given
- G8694Current or prior left ventricular ejection fraction (lvef) < = 40% or documentation of moderate or severe lvsd
- G8696Antithrombotic therapy prescribed at discharge
- G8697Antithrombotic therapy not prescribed for documented reasons (e.g., patient had stroke during hospital stay, patient expired during inpatient stay, other medical reason(s)); (e.g., patient left against medical advice, other patient reason(s))
- G8698Antithrombotic therapy was not prescribed at discharge, reason not given
- G8699Rehabilitation services (occupational, physical or speech) ordered at or prior to discharge
- G8700Rehabilitation services (occupational, physical or speech) not indicated at or prior to discharge
- G8701Rehabilitation services were not ordered, reason not otherwise specified
- G8702Documentation that prophylactic antibiotics were given within 4 hours prior to surgical incision or intraoperatively
- G8703Documentation that prophylactic antibiotics were neither given within 4 hours prior to surgical incision nor intraoperatively
- G870412-lead electrocardiogram (ecg) performed
- G8705Documentation of medical reason(s) for not performing a 12-lead electrocardiogram (ecg)
- G8706Documentation of patient reason(s) for not performing a 12-lead electrocardiogram (ecg)
- G870712-lead electrocardiogram (ecg) not performed, reason not given
- G8708Patient not prescribed antibiotic
- G8709Uri episodes when the patient had competing diagnoses on or three days after the episode date (e.g., intestinal infection, pertussis, bacterial infection, lyme disease, otitis media, acute sinusitis, acute pharyngitis, acute tonsillitis, chronic sinusitis, infection of the pharynx/larynx/tonsils/adenoids, prostatitis, cellulitis, mastoiditis, or bone infections, acute lymphadenitis, impetigo, skin staph infections, pneumonia/gonococcal infections, venereal disease (syphilis, chlamydia, inflammatory diseases [female reproductive organs]), infections of the kidney, cystitis or uti, and acne)
- G8710Patient prescribed antibiotic
- G8711Prescribed antibiotic on or within 3 days after the episode date
- G8712Antibiotic not prescribed or dispensed
- G8713Spkt/v greater than or equal to 1.2 (single-pool clearance of urea [kt] / volume [v])
- G8714Hemodialysis treatment performed exactly three times per week for > 90 days
- G8717Spkt/v less than 1.2 (single-pool clearance of urea [kt] / volume [v]), reason not given
- G8718Total kt/v greater than or equal to 1.7 per week (total clearance of urea [kt] / volume [v])
- G8720Total kt/v less than 1.7 per week (total clearance of urea [kt] / volume [v])
- G8721Pt category (primary tumor), pn category (regional lymph nodes), and histologic grade were documented in pathology report
- G8722Documentation of medical reason(s) for not including the pt category, the pn category or the histologic grade in the pathology report (e.g., re-excision without residual tumor; non-carcinomasanal canal)
- G8723Specimen site is other than anatomic location of primary tumor
- G8724Pt category, pn category and histologic grade were not documented in the pathology report, reason not given
- G8725Fasting lipid profile performed (triglycerides, ldl-c, hdl-c and total cholesterol)
- G8726Clinician has documented reason for not performing fasting lipid profile (e.g., patient declined, other patient reasons)
- G8728Fasting lipid profile not performed, reason not given
- G8730Pain assessment documented as positive using a standardized tool and a follow-up plan is documented
- G8731Pain assessment using a standardized tool is documented as negative, no follow-up plan required
- G8732No documentation of pain assessment, reason not given
- G8733Elder maltreatment screen documented as positive and a follow-up plan is documented
- G8734Elder maltreatment screen documented as negative, follow-up is not required
- G8735Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given
- G8736Most current ldl-c <100mg/dl
- G8737Most current ldl-c >=100mg/dl
- G8738Left ventricular ejection fraction (lvef) < 40% or documentation of severely or moderately depressed left ventricular systolic function
- G8739Left ventricular ejection fraction (lvef) >= 40% or documentation as normal or mildly depressed left ventricular systolic function
- G8740Left ventricular ejection fraction (lvef) not performed or assessed, reason not given
- G8749Absence of signs of melanoma (tenderness, jaundice, localized neurologic signs such as weakness, or any other sign suggesting systemic spread) or absence of symptoms of melanoma (cough, dyspnea, pain, paresthesia, or any other symptom suggesting the possibility of systemic spread of melanoma)
- G8751Smoking status and exposure to second hand smoke in the home not assessed, reason not given
- G8752Most recent systolic blood pressure < 140 mmhg
- G8753Most recent systolic blood pressure >= 140 mmhg
- G8754Most recent diastolic blood pressure < 90 mmhg
- G8755Most recent diastolic blood pressure >= 90 mmhg
- G8756No documentation of blood pressure measurement, reason not given
- G8757All quality actions for the applicable measures in the chronic obstructive pulmonary disease (copd) measures group have been performed for this patient
- G8758All quality actions for the applicable measures in the inflammatory bowel disease (ibd) measures group have been performed for this patient
- G8759All quality actions for the applicable measures in the sleep apnea measures group have been performed for this patient
- G8761All quality actions for the applicable measures in the dementia measures group have been performed for this patient
- G8762All quality actions for the applicable measures in the parkinson's disease measures group have been performed for this patient
- G8763All quality actions for the applicable measures in the hypertension (htn) measures group have been performed for this patient
- G8764All quality actions for the applicable measures in the cardiovascular prevention measures group have bee performed for this patient
- G8765All quality actions for the applicable measures in the cataract measures group have been performed for this patient
- G8767Lipid panel results documented and reviewed (must include total cholesterol, hdl-c, triglycerides and calculated ldl-c)
- G8768Documentation of medical reason(s) for not performing lipid profile (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8769Lipid profile not performed, reason not given
- G8770Urine protein test result documented and reviewed
- G8771Documentation of diagnosis of chronic kidney disease
- G8772Documentation of medical reason(s) for not performing urine protein test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not cllinically appropriate)
- G8773Urine protein test was not performed, reason not given
- G8774Serum creatinine test result documented and reviewed
- G8775Documentation of medical reason(s) for not performing serum creatinine test (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8776Serum creatinine test not performed, reason not given
- G8777Diabetes screening test performed
- G8778Documentation of medical reason(s) for not performing diabetes screening test (e.g., patients with a diagnosis of diabetes, or with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8779Diabetes screening test not performed, reason not given
- G8780Counseling for diet and physical activity performed
- G8781Documentation of medical reason(s) for patient not receiving counseling for diet and physical activity (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8782Counseling for diet and physical activity not performed, reason not given
- G8783Normal blood pressure reading documented, follow-up not required
- G8784Patient not eligible (e.g., documentation the patient is not eligible due to active diagnosis of hypertension, patient refuses, urgent or emergent situation)
- G8785Blood pressure reading not documented, reason not given
- G8797Specimen site other than anatomic location of esophagus
- G8798Specimen site other than anatomic location of prostate
- G8806Performance of trans-abdominal or trans-vaginal ultrasound and pregnancy location documented
- G8807Trans-abdominal or trans-vaginal ultrasound not performed for reasons documented by clinician (e.g., patient has a documented intrauterine pregnancy [iup])
- G8808Trans-abdominal or trans-vaginal ultrasound not performed, reason not given
- G8809Rh-immunoglobulin (rhogam) ordered
- G8810Rh-immunoglobulin (rhogam) not ordered for reasons documented by clinician (e.g., patient had prior documented receipt of rhogam within 12 weeks, patient refusal)
- G8811Documentation rh-immunoglobulin (rhogam) was not ordered, reason not given
- G8815Documented reason in the medical records for why the statin therapy was not prescribed (i.e., lower extremity bypass was for a patient with non-artherosclerotic disease)
- G8816Statin medication prescribed at discharge
- G8817Statin therapy not prescribed at discharge, reason not given
- G8818Patient discharge to home no later than post-operative day #7
- G8825Patient not discharged to home by post-operative day #7
- G8826Patient discharged to home no later than post-operative day #2 following evar
- G8833Patient not discharged to home by post-operative day #2 following evar
- G8834Patient discharged to home no later than post-operative day #2 following cea
- G8838Patient not discharged to home by post-operative day #2 following cea
- G8839Sleep apnea symptoms assessed, including presence or absence of snoring and daytime sleepiness
- G8840Documentation of reason(s) for not documenting an assessment of sleep symptoms (e.g., patient didn't have initial daytime sleepiness, patient visited between initial testing and initiation of therapy)
- G8841Sleep apnea symptoms not assessed, reason not given
- G8842Apnea hypopnea index (ahi), respiratory disturbance index (rdi) or respiratory event index (rei) documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea
- G8843Documentation of reason(s) for not measuring an apnea hypopnea index (ahi), a respiratory disturbance index (rdi), or a respiratory event index (rei) within 2 months after initial evaluation for suspected obstructive sleep apnea (e.g., medical, neurological, or psychiatric disease that prohibits successful completion of a sleep study, patients for whom a sleep study would present a bigger risk than benefit or would pose an undue burden, dementia, patients previously diagnosed with osa and severity assessed by another provider, patients who decline ahi/rdi/rei measurement, patients who had a financial reason for not completing testing, test was ordered but not completed, patients decline because their insurance (payer) does not cover the expense)
- G8844Apnea hypopnea index (ahi), respiratory disturbance index (rdi), or respiratory event index (rei) not documented or measured within 2 months after initial evaluation for suspected obstructive sleep apnea, reason not given
- G8845Positive airway pressure therapy prescribed
- G8846Moderate or severe obstructive sleep apnea (apnea hypopnea index (ahi) or respiratory disturbance index (rdi) of 15 or greater)
- G8848Mild obstructive sleep apnea (apnea hypopnea index (ahi) or respiratory disturbance index (rdi) of less than 15)
- G8849Documentation of reason(s) for not prescribing positive airway pressure therapy (e.g., patient unable to tolerate, alternative therapies use, patient declined, financial, insurance coverage)
- G8850Positive airway pressure therapy not prescribed, reason not given
- G8851Adherence to therapy was assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available, documented)
- G8852Positive airway pressure therapy was prescribed
- G8853Positive airway pressure therapy not prescribed
- G8854Documentation of reason(s) for not objectively reporting adherence to evidence-based therapy (e.g., patients who have been diagnosed with a terminal or advanced disease with an expected life span of less than 6 months, patients who decline therapy, patients who do not return for follow-up at least annually, patients unable to access/afford therapy, patient's insurance will not cover therapy)
- G8855Adherence to therapy was not assessed at least annually through an objective informatics system or through self-reporting (if objective reporting is not available), reason not given
- G8856Referral to a physician for an otologic evaluation performed
- G8857Patient is not eligible for the referral for otologic evaluation measure (e.g., patients who are already under the care of a physician for acute or chronic dizziness)
- G8858Referral to a physician for an otologic evaluation not performed, reason not given
- G8859Patient receiving corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days
- G8860Patients who have received dose of corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days
- G8861Within the past 2 years, central dual-energy x-ray absorptiometry (dxa) ordered and documented, review of systems and medication history or pharmacologic therapy (other than minerals/vitamins) for osteoporosis prescribed
- G8862Patients not receiving corticosteroids greater than or equal to 10mg/day for 60 or greater consecutive days
- G8863Patients not assessed for risk of bone loss, reason not given
- G8864Pneumococcal vaccine administered or previously received
- G8865Documentation of medical reason(s) for not administering or previously receiving pneumococcal vaccine (e.g., patient allergic reaction, potential adverse drug reaction)
- G8866Documentation of patient reason(s) for not administering or previously receiving pneumococcal vaccine (e.g., patient refusal)
- G8867Pneumococcal vaccine not administered or previously received, reason not given
- G8868Patients receiving a first course of anti-tnf therapy
- G8869Patient has documented immunity to hepatitis b and initiating anti-tnf therapy
- G8870Hepatitis b vaccine injection administered or previously received and is receiving a first course of anti-tnf therapy
- G8871Patient not receiving a first course of anti-tnf therapy
- G8872Excised tissue evaluated by imaging intraoperatively to confirm successful inclusion of targeted lesion
- G8873Patients with needle localization specimens which are not amenable to intraoperative imaging such as mri needle wire localization, or targets which are tentatively identified on mammogram or ultrasound which do not contain a biopsy marker but which can be verified on intraoperative inspection or pathology (e.g., needle biopsy site where the biopsy marker is remote from the actual biopsy site)
- G8874Excised tissue not evaluated by imaging intraoperatively to confirm successful inclusion of targeted lesion
- G8875Clinician diagnosed breast cancer preoperatively by a minimally invasive biopsy method
- G8876Documentation of reason(s) for not performing minimally invasive biopsy to diagnose breast cancer preoperatively (e.g., lesion too close to skin, implant, chest wall, etc., lesion could not be adequately visualized for needle biopsy, patient condition prevents needle biopsy [weight, breast thickness, etc.], duct excision without imaging abnormality, prophylactic mastectomy, reduction mammoplasty, excisional biopsy performed by another physician)
- G8877Clinician did not attempt to achieve the diagnosis of breast cancer preoperatively by a minimally invasive biopsy method, reason not given
- G8878Sentinel lymph node biopsy procedure performed
- G8879Clinically node negative (t1n0m0 or t2n0m0) invasive breast cancer
- G8880Documentation of reason(s) sentinel lymph node biopsy not performed (e.g., reasons could include but not limited to; non-invasive cancer, incidental discovery of breast cancer on prophylactic mastectomy, incidental discovery of breast cancer on reduction mammoplasty, pre-operative biopsy proven lymph node (ln) metastases, inflammatory carcinoma, stage 3 locally advanced cancer, recurrent invasive breast cancer, clinically node positive after neoadjuvant systemic therapy, patient refusal after informed consent, patient with significant age, comorbidities, or limited life expectancy and favorable tumor; adjuvant systemic therapy unlikely to change)
- G8881Stage of breast cancer is greater than t1n0m0 or t2n0m0
- G8882Sentinel lymph node biopsy procedure not performed, reason not given
- G8883Biopsy results reviewed, communicated, tracked and documented
- G8884Clinician documented reason that patient's biopsy results were not reviewed
- G8885Biopsy results not reviewed, communicated, tracked or documented
- G8886Most recent blood pressure under control
- G8887Documentation of medical reason(s) for most recent blood pressure not being under control (e.g., patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8888Most recent blood pressure not under control, results documented and reviewed
- G8889No documentation of blood pressure measurement, reason not given
- G8890Most recent ldl-c under control, results documented and reviewed
- G8891Documentation of medical reason(s) for most recent ldl-c not under control (e.g., patients with palliative goals for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8892Documentation of medical reason(s) for not performing ldl-c test (e.g. patients with palliative goals or for whom treatment of hypertension with standard treatment goals is not clinically appropriate)
- G8893Most recent ldl-c not under control, results documented and reviewed
- G8894Ldl-c not performed, reason not given
- G8895Oral aspirin or other antithrombotic therapy prescribed
- G8896Documentation of medical reason(s) for not prescribing oral aspirin or other antithrombotic therapy (e.g., patient documented to be low risk or patient with terminal illness or treatment of hypertension with standard treatment goals is not clinically appropriate, or for whom risk of aspirin or other antithrombotic therapy exceeds potential benefits such as for individuals whose blood pressure is poorly controlled)
- G8897Oral aspirin or other antithrombotic therapy was not prescribed, reason not given
- G8898I intend to report the chronic obstructive pulmonary disease (copd) measures group
- G8899I intend to report the inflammatory bowel disease (ibd) measures group
- G8900I intend to report the sleep apnea measures group
- G8902I intend to report the dementia measures group
- G8903I intend to report the parkinson's disease measures group
- G8904I intend to report the hypertension (htn) measures group
- G8905I intend to report the cardiovascular prevention measures group
- G8906I intend to report the cataract measures group
- G8907Patient documented not to have experienced any of the following events: a burn prior to discharge; a fall within the facility; wrong site/side/patient/procedure/implant event; or a hospital transfer or hospital admission upon discharge from the facility
- G8908Patient documented to have received a burn prior to discharge
- G8909Patient documented not to have received a burn prior to discharge
- G8910Patient documented to have experienced a fall within asc
- G8911Patient documented not to have experienced a fall within ambulatory surgical center
- G8912Patient documented to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event
- G8913Patient documented not to have experienced a wrong site, wrong side, wrong patient, wrong procedure or wrong implant event
- G8914Patient documented to have experienced a hospital transfer or hospital admission upon discharge from asc
- G8915Patient documented not to have experienced a hospital transfer or hospital admission upon discharge from asc
- G8916Patient with preoperative order for iv antibiotic surgical site infection (ssi) prophylaxis, antibiotic initiated on time
- G8917Patient with preoperative order for iv antibiotic surgical site infection (ssi) prophylaxis, antibiotic not initiated on time
- G8918Patient without preoperative order for iv antibiotic surgical site infection (ssi) prophylaxis
- G8923Current or prior left ventricular ejection fraction (lvef) <= 40% or documentation of moderately or severely depressed left ventricular systolic function
- G8924Spirometry results documented (fev1/fvc < 70%)
- G8925Spirometry test results demonstrate fev1 >= 60% fev1/fvc >= 70%, predicted or patient does not have copd symptoms
- G8926Spirometry test not performed or documented, reason not given
- G8927Adjuvant chemotherapy referred, prescribed or previously received for ajcc stage iii, colon cancer
- G8928Adjuvant chemotherapy not prescribed or previously received, for documented reasons (e.g., medical co-morbidities, diagnosis date more than 5 years prior to the current visit date, patient's diagnosis date is within 120 days of the end of the 12 month reporting period, patient's cancer has metastasized, medical contraindication/allergy, poor performance status, other medical reasons, patient refusal, other patient reasons, patient is currently enrolled in a clinical trial that precludes prescription of chemotherapy, other system reasons)
- G8929Adjuvant chemotherapy not prescribed or previously received, reason not given
- G8930Assessment of depression severity at the initial evaluation
- G8931Assessment of depression severity not documented, reason not given
- G8932Suicide risk assessed at the initial evaluation
- G8933Suicide risk not assessed at the initial evaluation, reason not given
- G8934Current or prior left ventricular ejection fraction (lvef) <=40% or documentation of moderately or severely depressed left ventricular systolic function
- G8935Clinician prescribed angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy
- G8936Clinician documented that patient was not an eligible candidate for angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy (eg, allergy, intolerance, pregnancy, renal failure due to ace inhibitor, diseases of the aortic or mitral valve, other medical reasons) or (eg, patient declined, other patient reasons)
- G8937Clinician did not prescribe angiotensin converting enzyme (ace) inhibitor or angiotensin receptor blocker (arb) therapy, reason not given
- G8938Bmi is documented as being outside of normal parameters, follow-up plan is not documented, documentation the patient is not eligible
- G8939Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible at the time of the encounter
- G8940Screening for depression documented as positive, a follow-up plan not completed, documented reason
- G8941Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible for follow-up plan at the time of the encounter
- G8942Functional outcome assessment using a standardized tool is documented within the previous 30 days and a care plan, based on identified deficiencies is documented within two days of the functional outcome assessment
- G8943Ldl-c result not present or not within 12 months prior
- G8944Ajcc melanoma cancer stage 0 through iic melanoma
- G8946Minimally invasive biopsy method attempted but not diagnostic of breast cancer (e.g., high risk lesion of breast such as atypical ductal hyperplasia, lobular neoplasia, atypical lobular hyperplasia, lobular carcinoma in situ, atypical columnar hyperplasia, flat epithelial atypia, radial scar, complex sclerosing lesion, papillary lesion, or any lesion with spindle cells)
- G8947One or more neuropsychiatric symptoms
- G8948No neuropsychiatric symptoms
- G8949Documentation of patient reason(s) for patient not receiving counseling for diet and physical activity (e.g., patient is not willing to discuss diet or exercise interventions to help control blood pressure, or the patient said he/she refused to make these changes)
- G8950Elevated or hypertensive blood pressure reading documented, and the indicated follow-up is documented
- G8951Pre-hypertensive or hypertensive blood pressure reading documented, indicated follow-up not documented, documentation the patient is not eligible
- G8952Elevated or hypertensive blood pressure reading documented, indicated follow-up not documented, reason not given
- G8953All quality actions for the applicable measures in the oncology measures group have been performed for this patient
- G8955Most recent assessment of adequacy of volume management documented
- G8956Patient receiving maintenance hemodialysis in an outpatient dialysis facility
- G8957Patient not receiving maintenance hemodialysis in an outpatient dialysis facility
- G8958Assessment of adequacy of volume management not documented, reason not given
- G8959Clinician treating major depressive disorder communicates to clinician treating comorbid condition
- G8960Clinician treating major depressive disorder did not communicate to clinician treating comorbid condition, reason not given
- G8961Cardiac stress imaging test primarily performed on low-risk surgery patient for preoperative evaluation within 30 days preceding this surgery
- G8962Cardiac stress imaging test performed on patient for any reason including those who did not have low risk surgery or test that was performed more than 30 days preceding low risk surgery
- G8963Cardiac stress imaging performed primarily for monitoring of asymptomatic patient who had pci within 2 years
- G8964Cardiac stress imaging test performed primarily for any other reason than monitoring of asymptomatic patient who had pci within 2 years (e.g., symptomatic patient, patient greater than 2 years since pci, initial evaluation, etc)
- G8965Cardiac stress imaging test primarily performed on low chd risk patient for initial detection and risk assessment
- G8966Cardiac stress imaging test performed on symptomatic or higher than low chd risk patient or for any reason other than initial detection and risk assessment
- G8967Fda approved oral anticoagulant is prescribed
- G8968Documentation of medical reason(s) for not prescribing an fda-approved anticoagulant (e.g., present or planned atrial appendage occlusion or ligation or patient being currently enrolled in a clinical trial related to af/atrial flutter treatment)
- G8969Documentation of patient reason(s) for not prescribing an oral anticoagulant that is fda approved for the prevention of thromboembolism (e.g., patient preference for not receiving anticoagulation)
- G8970No risk factors or one moderate risk factor for thromboembolism
- G8971Warfarin or another oral anticoagulant that is fda approved not prescribed, reason not given
- G8972One or more high risk factors for thromboembolism or more than one moderate risk factor for thromboembolism
- G8973Most recent hemoglobin (hgb) level < 10 g/dl
- G8974Hemoglobin level measurement not documented, reason not given
- G8975Documentation of medical reason(s) for patient having a hemoglobin level < 10 g/dl (e.g., patients who have non-renal etiologies of anemia [e.g., sickle cell anemia or other hemoglobinopathies, hypersplenism, primary bone marrow disease, anemia related to chemotherapy for diagnosis of malignancy, postoperative bleeding, active bloodstream or peritoneal infection], other medical reasons)
- G8976Most recent hemoglobin (hgb) level >= 10 g/dl
- G8977I intend to report the oncology measures group
- G8978Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals
- G8979Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8980Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end reporting
- G8981Changing & maintaining body position functional limitation, current status, at therapy episode outset and at reporting intervals
- G8982Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8983Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end reporting
- G8984Carrying, moving & handling objects functional limitation, current status, at therapy episode outset and at reporting intervals
- G8985Carrying, moving and handling objects, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8986Carrying, moving & handling objects functional limitation, discharge status, at discharge from therapy or to end reporting
- G8987Self care functional limitation, current status, at therapy episode outset and at reporting intervals
- G8988Self care functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8989Self care functional limitation, discharge status, at discharge from therapy or to end reporting
- G8990Other physical or occupational therapy primary functional limitation, current status, at therapy episode outset and at reporting intervals
- G8991Other physical or occupational therapy primary functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8992Other physical or occupational therapy primary functional limitation, discharge status, at discharge from therapy or to end reporting
- G8993Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset and at reporting intervals
- G8994Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8995Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from therapy or to end reporting
- G8996Swallowing functional limitation, current status at therapy episode outset and at reporting intervals
- G8997Swallowing functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting
- G8998Swallowing functional limitation, discharge status, at discharge from therapy or to end reporting
- G8999Motor speech functional limitation, current status at therapy episode outset and at reporting intervals