SET 10 Appendix E 1

User Manual: SET-10

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American Academy of Neurology

Multiple Sclerosis

Quality Measurement Set

Approved by the Multiple Sclerosis Quality Measurement Development Work Group on February 12,

2015, by the AAN Quality and Safety Subcommittee on February 20, 2015; by the AAN Practice

Committee on March 10, 2015; and by the AANI Board of Directors on March 24, 2015.

This measurement set was endorsed by the American Association of Neuroscience Nurses

on March 13, 2015.

Disclaimer

Performance Measures (Measures) and related data specifications developed by the American Academy

of Neurology (AAN) are intended to facilitate quality improvement activities by providers.

AAN Measures: 1) are not clinical guidelines and do not establish a standard of medical care, and have

not been tested for all potential applications; 2) are not continually updated and may not reflect the most

recent information; and 3) are subject to review and may be revised or rescinded at any time by the AAN.

The measures, while copyrighted, can be reproduced and distributed, without modification, for

noncommercial purposes (e.g., use by health care providers in connection with their practices); they must

not be altered without prior written approval from the AAN. Commercial use is defined as the sale,

license, or distribution of the measures for commercial gain, or incorporation of the measures into a

product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the

measures require a license agreement between the user and the AAN. Neither the AAN nor its members

are responsible for any use of the measures.

AAN Measures and related data specifications do not mandate any particular course of medical care and

are 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. AAN provides this information on an “as is” basis, and makes no

warranty, expressed or implied, regarding the information. AAN specifically disclaims any warranties of

merchantability or fitness for a particular use or purpose. AAN 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 AAN

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

Standards Development Organization

Table of Contents

Page

Work Group Members

Improving Outcomes for Patients with Multiple Sclerosis (MS)

Clinical Evidence Base

Definitions and Abbreviations

Desired Outcomes

Work Group Recommendations

Other Potential Measures

Intended Care Audience, Settings, and Patient Population

Measure Harmonization

Technical Specifications Overview

Measure Exceptions

Testing and Implementation of the Measurement Set

Multiple Sclerosis Measurement Set

1. Multiple Sclerosis (MS) Diagnosis

2. Comparison MRI Within 24 Months of MS Diagnosis

3. Current MS Disability Scale Score

4. Fall Risk Screening for Patients with MS

5. Bladder Infections for Patients with MS

6. Exercise and Appropriate Physical Activity Counseling for Patients with MS

7. Fatigue Outcome for Patients with MS

8. Cognitive Impairment Testing for Patients with MS

9. Clinical Depression Screening for Patients with MS

10. Depression Outcome for Patients with MS

11. Maintained or Improved Baseline Quality of Life for Patients with MS

Contact Information

References

Multiple Sclerosis Work Group Members

Co-Chairs

Christopher Bever, MD, MBA, FAAN

Alexander Rae-Grant, MD, FRCP(C)

American Academy of Neurology

Barbara Giesser, MD, FAAN

Douglas Jeffery, MD, PhD

Mitch Wallin, MD, MPH

Mary Alissa Willis, MD

American Academy of Physical Medicine and

Rehabilitation

K. Rao Poduri, MD, FAA PMR

American Association of Neuroscience Nurses

Patricia Pagnotta, MSN, ARNP, CNRN, MSCN

American Association of Nurse Practitioners

Carrie Sammarco, DrNP, FNP-C, MSCN

American Occupational Therapy Association

Virgil Mathiowetz, PhD, OTR/L, FAOTA

American Physical Therapy Association

Amy Yorke, PT, PhD, NCS

American Psychiatric Association

Melanie Schwarz, MD

American Society of Neurorehabiltation

Victor Mark, MD

Anthem

Ronald Koenig, MD, FAAN

National Academy of Neuropsychology

John DeLuca, PhD

Consortium of Multiple Sclerosis Centers

June Halper, MSN, APN-C, MSCN, FAAN

Multiple Sclerosis Association of America

Cindy Richman

Multiple Sclerosis Foundation

Annette Okai, MD

National Multiple Sclerosis Society

Nicholas LaRocca, PhD

National Multiple Sclerosis Society – Midwest

Chapter

William MacNally, MHA, FACHE

Work Group Facilitators

Eric Cheng, MD, MS, FAAN

Michael Phipps, MD, MHS

Amy Sanders, MD, MS

American Academy of Neurology Staff

Amy Bennett, JD

Gina Gjorvad

Erin Hagen

Becky Schierman, MPH

Declined

Aetna, American Academy of Family

Physicians, American Academy of

Ophthalmology, American Chronic Pain

Association, American Congress of

Rehabilitation Medicine, American Pain

Society, American Psychological Association,

Cigna, First Coast Service Options, Health Net,

Highmark, Humana, Paralyzed Veterans of

America, United Healthcare

Improving Outcomes for Patients with Multiple Sclerosis (MS)

Purpose of Measurement Set

In 2014, the American Academy of Neurology (AAN) formed a multi-disciplinary Multiple Sclerosis

Work Group (Work Group) to review existing guidelines and evidence, gaps in care and to develop a

measurement set for multiple sclerosis (MS) to promote quality improvement and drive improved

outcomes for patients with MS.

The AAN develops quality measures based on the belief that neurologists should play a major role in

selecting and creating performance measures that will drive performance improvement and possibly be

used in accountability programs. The AAN formed the Work Group with representatives from

professional associations, patient advocacy organizations, and payers to ensure measures developed

include input from all members of the healthcare team. All members of the Work Group were required to

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

interest.

Topic Importance

It is estimated that MS affects about 400,000 Americans and is the leading cause of disability among

young adults.

The disorder generally worsens over time, leading to irreversible functional disability

with symptoms including visual or sensory disturbances, loss of strength, tremor, ambulatory problems,

loss of bladder/bowel control, fatigue, spasticity, cognitive impairment and sexual dysfunction. Further,

the number of people with MS worldwide is approximately 2.3 to 2.5 million.

MS is not a “reportable”

disease in the United States, which makes it difficult to determine an accurate number of individuals who

have MS.

There are twice as many women with MS as men with MS overall.3 Geographic differences in

the prevalence of MS in the United States have been noted.

80% of patients present with an initial episode of neurological symptoms, which can either represent a

clinically isolated syndrome or multiple sclerosis depending on clinical and magnetic resonance imaging

(MRI) factors. Of these those who have white-matter abnormalities on MRI, the chance of a second attack

subsequently occurring increases from 50% at 2 years to 82% at 20 years.

Progression to the secondary

progressive phase starts at varying age but averages about 40 years of age.7

Compston notes that death is attributable to MS in two-thirds of cases and to increased infection risks and

complications in others.7 The median time to death is around 30 years from disease onset, which

represents a reduction in life expectancy of 5-10 years.7

The cost of MS is rapidly rising given the advances of in therapies. A review of the cost burden of MS

indicated the mean cost for patients with MS ranged from $8,528-$54,244 per year and direct costs,

including hospitalization, outpatient care and pharmaceuticals, ranged from $6,144-$34,511 in 2011

dollars.

Prescription drugs and indirect costs, such as disease-related absences from work, were the

biggest single cost drivers of MS representing an average of 50% and 23% of total costs.8 This high cost

burden review did not include newer, more costly therapies.8

Opportunities for Improvement

Additional data on opportunities for improvement and gaps in care specific to the MS measures can be

located in the quality measurement set that follows. Treatment use remains uneven, and treatment of MS

is much debated due to the fact available treatments are expensive and do not always meet routine

standards for cost-effectiveness.8

Clinical Evidence Base

The MS Work Group reviewed existing literature and consulted MS clinical practice guidelines including:

1. Assessment and Management of Psychiatric Disorders in Individuals with MS: Report of the

Guideline Development Subcommittee of the American Academy of Neurology.

2. Evidence report: the efficacy and safety of mitoxantrone (Novantrone) in the treatment of

multiple sclerosis.

3. Neutralizing antibodies to interferon beta: Assessment of their clinical and radiographic impact:

An evidence report.

4. Evidence-based guideline update: plasmapheresis in neurologic disorders.

5. Evidence-based guideline: clinical evaluation and treatment of transverse myelitis.

6. Practice parameter: The usefulness of evoked potentials in identifying clinically silent lesions in

patients with suspected multiple sclerosis (an evidence-based review): Report of the Quality

Standards Subcommittee of the American Academy of Neurology.

7. Evidence-based guideline: Complementary and alternative medicine in multiple sclerosis.

8. Multiple sclerosis: management of multiple sclerosis in primary and secondary care.

9. Nursing management of the patient with multiple sclerosis.

10. EFNS guidelines on the use of anti-interferon beta antibody measurements in multiple sclerosis.

11. EFNS guidelines on acute relapses of multiple sclerosis.

12. Fingolimod for the treatment of highly active relapsing-remitting multiple sclerosis.

13. Consortium of MS Centers MRI Protocol for the Diagnosis and Follow-up of MS 2009 Revised

Guidelines.

14. The importance of quality-of-life assessment in the management of patients with multiple

sclerosis Recommendations from the Middle East MS Advisory Group.

Definitions and Abbreviations in the Measurement Set

The Work Group utilized the following definitions and abbreviations in the measurement set:

 Consult: to ask the advice or opinion of (Merriam-Webster

)

 Counsel: to advise seriously and formally after consultation (Merriam-Webster

)

 Educate: to give someone information or training about something (Merriam-Webster

)

 Refer: to send or direct for diagnosis or treatment (Merriam-Webster

)

 Screen: to test or examine for the presence of something (Merriam-Webster

)

Below is a list of acronyms utilized in this document. The AAN has a Quality Improvement Glossary,

which provides more in depth explanations and is available at aan.com/practice/quality-measures/quality-

resources.

 ACO: Accountable Care Organization

 ADL: Activities of Daily Living

 CMS: Centers for Medicare & Medicaid Services

 DMT: Disease Modifying Therapy

 MS: Multiple Sclerosis

 NQF: National Quality Forum

 PQRS: Physician Quality Reporting System

 QOL: Quality of Life

Desired Outcomes

The Work Group reviewed desired outcomes for patients with MS and identified the following:

• Confirmation of MS diagnosis as soon as possible

• Reduce mortality directly related to MS

• Reduce MS progression

• Reduce MS exacerbation frequency

• Maintain or increase existing cognitive and physical functioning levels

• Reduce affective symptoms in patient population, which include, but are not limited to emotional

lability, depression, and anxiety

• Reduce falls

• Improve adherence to Disease Modifying Therapy (DMT)

• Increase patients engagement in treatment decision process

• Increase patients acting on received MS education and incorporating information into treatment

• Improve quality of care from a coordinated treatment team

• Address all patient needs and engage all patients on a personal level

• Increase patient satisfaction with care provided

• Reduce caregiver burden

• Decrease rates of comorbidities (i.e., HTN, Diabetes, Smoking Obesity)

• Increase Quality of Life ratings

• Reduce hospitalizations

• Decrease complications of MS:

• Pressure Ulcers

• Fatigue

• Spasticity

• Pain and Headache

• Sexual Dysfunction

• Bowel and Urinary Dysfunction

Work Group Recommendations

The Work Group recommended the following measures be developed.

Multiple Sclerosis Measurement Set

1. Multiple Sclerosis (MS) Diagnosis

2. Comparison MRI Within 24 Months of MS Diagnosis

3. Current MS Disability Scale Score

4. Fall Risk Screening for Patients with MS

5. Bladder Infections for Patients with MS

6. Exercise and Appropriate Physical Activity Counseling for Patients with MS

7. Fatigue Outcome for Patients with MS

8. Cognitive Impairment Testing for Patients with MS

9. Clinical Depression Screening for Patients with MS

10. Depression Outcome for Patients with MS

11. Maintained or Improved Baseline Quality of Life for Patients with MS

Other Potential Measures

It is impossible for one quality measurement set to address all MS quality of care issues. At the

beginning of this project, it was determined the scope would be limited. Neuromyelitis Optica (NMO)

and Clinically Isolated Syndrome (CIS) measures were excluded from project scope.

The Work Group evaluated possible MS relapse measures. Development of a relapse measure was

deemed to be of high importance given the fact that reduction of the number of relapses is considered to

be one of the most important desired outcomes for a patient with MS. However, potential measure drafts

were noted to be potentially cost inefficient, difficult or impossible to measure, difficult or impossible for

a practitioner to act upon. Possible relapse measures discussed included:

 The percentage of patients with multiple sclerosis who demonstrate a response to treatment at

twelve months defined by a reduction of new lesion formation and active lesions on MRI from

prior MRI in measurement period.

 Percentage of patients with multiple sclerosis who did not require steroids or inpatient treatment

during a 12-month period.

 Percentage of patients with multiple sclerosis who demonstrate a response to treatment at twelve

months defined by maintenance or improvement of Expanded Disability Scale Score (EDSS).

 Percentage of patients with relapsing or secondary progressive MS with relapses in a given

population during a 12-month period. (Such a measure would be useful for comparisons of

different MS centers.)

 Percentage of patients with MS with defined relapses affecting function offered treatment for

their relapses/number of patients with defined relapses.

 Percentage of patients with multiple sclerosis who reported relapses.

The Work Group also considered a treatment complication – spasticity measure. A lack of adequate

outcome scale prevented further development of such a measure. Lack of uniformity in documenting

spasticity evaluation and an electronic health record (EHR) variability exacerbated spasticity measure

development (i.e., most spasticity evaluations are recorded in an EHR as free form text, which would

result in a manual chart review.)

The Work Group discussed development of a measure related to DMT, but was unable to locate published

data supporting a treatment gap in care. There were also concerns that a denominator cannot be readily

identified using administrative data with limitations in ICD coding. The Work Group developed measure

concepts to address mobility and visual deficits, but did not approve these concepts for further

development following the in person meeting.

The Work Group approved pain assessment and fall follow-up plan documented measures for public

comment. These measures were withdrawn following public comment. The pain assessment measure was

withdrawn due to concern that it unnecessarily duplicates existing measures. The Work Group encourages

individuals to consider National Quality Forum (NQF) endorsed measure #0420 and adopted into

Physician Quality Reporting System (PQRS) measure #131. The fall follow-up measure was withdrawn

due to potential difficulty locating follow-up plan documentation. Locating follow-up plan documentation

would potentially require burdensome chart review, as the information would not be easily accessed in an

EHR.

Intended Care Audience, Settings, and Patient Population

The AAN encourages use of these measures by physicians, other health care professionals, and the health

care systems, where appropriate, to achieve improved performance and as steps towards optimized

clinical outcomes for patients with MS. The Work Group included adolescent populations for select

measures where appropriate and supported by the evidence.

Not all AAN measures are appropriate for accountability programs, and the MS Work Group has

designated appropriate measures use in the measure descriptions that follow. The following is a summary

of measures recommended for use in accountability programs.

Multiple Sclerosis Measurement Set

Recommended for

Accountability Programs

1. Multiple Sclerosis (MS) Diagnosis

2. Comparison MRI Within 24 Months of MS Diagnosis

3. Current MS Disability Scale Score

Yes

4. Fall Risk Screening for Patients with MS

Yes

5. Bladder Infections for Patients with MS

Yes

For System or Health Plans Only

6. Exercise and Appropriate Physical Activity Counseling for

Patients with MS

Yes

7. Fatigue Outcome for Patients with MS

Yes

For System or Health Plans Only

8. Cognitive Impairment Testing for Patients with MS

Yes

For System or Health Plans Only

9. Clinical Depression Screening for Patients with MS

Yes

10. Depression Outcome for Patients with MS

Yes

For System or Health Plans Only

11. Maintained or Improved Baseline Quality of Life for Patients

with MS

Yes

For System or Health Plans Only

Measure Harmonization

The MS Work Group searched for existing performance measures operating with a denominator of

patients with MS, and did not locate any. Cheng et al. created a list of quality indicators specific to MS

that was reviewed by the Work Group.

Efforts were made to unify denominator statements when

possible to ease data collection. Multiple measure sets exist that have potential implications for patients

with MS such as depression, urinary function, etc. Details on how these existing measures were

harmonized are included in the specific measure specifications that follow below.

Technical Specifications Overview

The AAN develops technical specifications for measures that may include:

 Electronic Health Record (EHR) Data

 Electronic Administrative Data (Claims)

 Chart Review (for select measures where EHR data cannot be gathered)

 Registry

Administrative claims specifications are provided for MS measures when applicable. The AAN is in the

process of creating code value sets and the logic required for electronic capture of the quality measures

with EHRs, when possible. A listing of the quality data model elements, code value sets, and measure

logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made available at

a later date. These technical specifications will be updated as warranted.

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.

Measure Exceptions

A denominator exclusion is a factor supported by the clinical evidence that removes a patient from

inclusion in the measure population. For example, if the denominator indicates the measure is for all

patients aged 0 to 18 years of age, a patient who is 19 years of age is excluded.

A denominator exception is a condition that should remove the patient, procedure or unit of measurement

from the denominator only if the numerator criteria are not met. The AAN includes three possible types

of exceptions for reasons why a patient should not be included in a measure denominator: medical (e.g.,

contraindication), patient (e.g., declination or religious belief), or system (e.g., resource limitation)

reasons. For each measure, there must be a clear rationale to permit an exception for a medical, patient, or

system reason. The Work Group provided explicit exceptions when applicable for ease of use in

eMeasure development.

Testing and Implementation of the Measurement Set

The MS 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. Any testing data gathered will be considered during future measurement set updates. Select

measures will be beta tested once the set has been released, prior to submission to the National Quality

Forum for possible endorsement. All readers are encouraged to read the AAN Statement on Comparing

Outcomes of Patients available in the AAN measurement manual. (https://www.aan.com/practice/quality-

measures/about-quality-measures/)

This measure set includes outcome measures which are intended to be applied at the system or

accountable care organization level. Use of these measures to compare providers or practices would

require the application of a valid risk adjustment methodology which does not exist for MS populations.

These measures may be used for accountability at the system or accountable care organization level if the

MS populations being compared are similar in demographics, socioeconomic status and the prevalence of

comorbid conditions. These measures may also be used for internal, non-publicly reported quality

improvement for a patient population that is not subject to significant change, as risk adjustment or

stratification would not be required.

The AAN encourages a minimum sample size of 20 for use in public reporting programs to reduce

likelihood of error. The number 20 reflects current CMS sample requirements for Physician Compare.

Multiple Sclerosis (MS) Diagnosis

Measure Description

Percentage of patients who received a new diagnosis of multiple sclerosis in the past 12 months who

fulfilled international criteria.*

Measure Components

Numerator

Statement

Patients who received a new diagnosis of multiple sclerosis in the past 12

months who fulfilled international criteria.*

Definitions:

*International criteria is use of the either the 2005 or 2010 revised McDonald

criteria.1,2 These criteria facilitate the diagnosis of MS, but do not protect

against misdiagnosis. Additional diagnostic evaluation may be needed, and

this must be tailored to each patient’s clinical situation.

Denominator

Statement

All patients with a new diagnosis of MS in the past 12 months.

Denominator

Exclusions

 Excluding other neuroimmunological syndromes including

 Neuromyelitis Optica,

 Clinically Isolated Syndrome,

 Radiologically Isolated Syndrome, and

 Acute Disseminated Encephalomyelitis.

Denominator

Exceptions

None

Supporting Guideline

& Other References

“A proportion of patients with nonspecific symptoms and nonspecific MRI

findings are referred to secondary and tertiary MS centers in the developed

world for a second opinion and do not in fact have MS.”1 Use of international

diagnostic criteria allows for a more rapid diagnosis of MS in some instances

and clarify and simplify the diagnostic process in many instances with fewer

MRI examinations.1, 2

Measure Importance

Relationship to

Desired Outcome

Desired outcome is to confirm diagnosis of MS in line with the most recent

internationally recognized criteria for the diagnosis. It is recognized that

excluding MS mimics is a key aspect of diagnosis which is not addressed by

this measure.3 Intention is to increase early diagnosis and treatment for

patients with MS and reduce costs of harms from delayed diagnosis of MS.

Patients meeting international diagnostic criteria for relapsing MS and

secondary progressive MS with relapses are potential candidate for disease

modifying therapy (DMT). It is anticipated that if measured, there is a

likelihood to reduce prescriptions and costs for patients not meeting DMT use

criteria who otherwise might be offered these treatments.

Opportunity for

Improvement

Diagnostic errors are common in MS.4,5 Misdiagnosis is a significant

contributor to patient harm.6 Increasing awareness and adherence to

international diagnostic criteria for MS is desired. A need to reduce the

population of patients using DMT who do not have MS by international

criteria exists. The measure does not require confirmation of diagnosis

through a second opinion or physician referral, but is intended to confirm

diagnosis only within the first twelve months of diagnosis or a referral to a

specialist.

National Quality

Strategy Domains

☐ Patient and Family Engagement

☒ Patient Safety

☒Care Coordination

☐ Population/Public Health

☒ Efficient Use of Healthcare Resources

☐ Clinical Process/Effectiveness

Exception

Justification

Not Applicable

Harmonization with

Existing Measures

There are currently no other comparable measures in national measurement

programs or endorsed by the National Quality Forum.

Measure Designation

Measure Purpose

(Check all that apply)

☒ Quality improvement

☐Accountability

Type of Measure

(Check all that apply)

☐Process

☒ Outcome

☐ Structure

Level of

Measurement (Check

all that apply)

☒ Individual Provider

☒ Practice

Care Setting (Check

all that apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source (Check

all that apply)

☐ Electronic health record (EHR) data

☒Administrative Data/Claims

☒ Chart Review

☒ Registry

References

1 Polman CH, Reingold SC, Banwell B, et al. Diagnostic Criteria for Multiple Sclerosis: 2010 Revisions to the

McDonald Criteria. Ann Neurol 2011; 69:292-302.

2 Polman CH, Reingold SC, Edan, G, et al. Diagnostic criteria for multiple sclerosis: 2005 revisions to the

“McDonald Criteria”. Annals of Neurology 2005; 58(6):840-846.

3 Miller DH, Weinshenker BG, Filippi M, et al. Differential diagnosis of suspected multiple sclerosis: a

consensus approach. Mult Scler 2008; 14:1157-1174.

4 Solomon AJ and Weinshenker BG. Misdiagnosis of Multiple Sclerosis: Frequency, Causes, Effects, and

Prevention. Curr Neurol Neurosci Rep 2013; 13:403.

5 Carmosino MJ, Brousseau KM, Arciniegas DB, et al. Initial Evaluations for Multiple Sclerosis in a University

Multiple Sclerosis Center. Arch Neurol 2005; 62:585-590.

6 El-Kareh R. Making Clinical Diagnoses: How Measureable Is the Process? National Quality Measures

Clearinghouse. May 5, 2014. Available at: http://www.qualitymeasures.ahrq.gov/expert/expert-

commentary.aspx?f=rss&id=47927

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New

Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-

Established Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient

Consultation-New or Established Patient)

Comparison MRI Within 24 Months of MS Diagnosis

Measure Description

Percentage of patients with MS who had an MRI with and without gadolinium within 24 months of

diagnosis compared with a baseline MRI.

Measure Components

Numerator

Statement

Patients with MS who had an MRI with and without gadolinium within 24 months

of diagnosis compared with a baseline MRI.

Denominator

Statement

All patients with a diagnosis of MS within the past 24 months.

Denominator

Exceptions

 Patient has clinically evident disease activity.

 Patient declines referral to MRI of brain and/or spinal cord for personal,

medical, or system reasons (i.e., claustrophobia).

 Patient meets MRI exclusions (i.e., any 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).

Supporting

Guideline &

Other

References

The following evidence statements are quoted verbatim from the referenced

clinical guidelines:

 “A brain MRI with gadolinium …for the following of MS patients to

assess subclinical disease activity should be CONSIDERED every 1 to 2

years.”1,2

Measure Importance

Relationship to

Desired

Outcome

The desired outcomes in MS patients are to prevent clinical relapses and to prevent

long term impairment and disability. Clinically apparent relapses are not fully

predictive of long term disability and prevention of relapses does not fully prevent

long term disability so more sensitive predictors of long term disability have been

sought. Disease activity that is seen on MRI, but not clinically evident, is

predictive of disability progression early in the disease course. Therefore, MRI is

being used as a sensitive biomarker of disease activity to judge long term

prognosis and to help guide the use of disease modifying therapies.

Opportunity for

Improvement

Prior to the recognition that MRI is more sensitive to MS disease activity than

monitoring of clinical symptoms, monitoring response to therapy was based

primarily on clinical symptoms. Because of this, many MS providers continue to

rely primarily on clinical evaluation to drive decision making in MS patients and

do not monitor MRI activity on a regular basis. Increasing the use of MRI

monitoring could lead to patients being moved to more effective therapies which

would reduce long term impairment and disability.

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☒ Population/Public Health

☐ Efficient Use of Healthcare Resources

☒ Clinical Process/Effectiveness

Exception

Justification

 Exception provided for patients who have clinically evident disease

activity to reduce unnecessary MRI testing.

 Exception for patient declinations need as patients need to be willing to

undergo a MRI.

 Exception for MRI exclusions necessary to avoid harm to patients.

Harmonization

with Existing

Measures

There are currently no other comparable measures in national measurement

programs or endorsed by the National Quality Forum.

Measure Designation

Measure

Purpose (check

all that apply)

☒ Quality improvement

☐ Accountability

Type of

Measure (check

all that apply)

☒ Process

☐ Outcome

☐ Structure

Level of

Measurement

(check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☐Electronic health record (EHR) data

☒ Administrative Data/Claims

☒Chart Review

☒ Registry

References

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

Follow-up of MS 2009 Revised Guidelines.

2 Simon JH, Li D, Traboulsee A, et al. Standardized MR imaging protocol for multiple sclerosis. Consortium of

MS Centers consensus guidelines. AJNR Am J Neuroradiol. 2006;27:455-461.

Additional Supporting References (Literature):

 Bagnato F, Tancredi A, Richert N, et al. Contrast-enhanced magnetic resonance activity in relapsing-

remitting multiple sclerosis. Mult Scler 2000; 6: 43-49.

 Rio J, Rovira A, Tintore M, et al. Evaluating the response to glatiramer acetate in relapsing-remitting

multiple sclerosis patients. Mult Scl 2014; Epub ahead of print, pubmed no 34622350.

 Bermel RA, You X, Foulds P, et al. Predictors of long-term outcome in patients treated with interferon-

beta. Ann Neurol 2013; 73: 95-103.

 Durelli L, Barbero P, Bergui M et al. MRI activity and neutralizing antibodies as predictors of response

to interferon-beta treatment in multiple sclerosis. J Neurol Neurosurg Psych 2008; 79: 646-651.

 Grimaldi LM, Prosperini L, Vittello G, et al. MRI-based analysis of the natalizumab therapeutic

window. Mult Scler 2012; 18: 1337-1339.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient)

Current MS Disability Scale Score

Measure Description

Percentage of patients with MS who have a MS disability scale score* documented in the medical

record in the past 12 months.

Measure Components

Numerator

Statement

Patients with MS who have a MS disability scale score* documented in the

medical record in the past 12 months.

*MS disability scale score is defined as the score obtained from administering one

of the following:

 Patient Determined Disease Steps (PDDS)1,

 At least 2 measures of MS Functional Composite (MSFC)2,

 Kurtzke Expanded Disability Status Scale (EDSS)3,4,

 European Database on MS Grading System (EDMUS-GS)5,6,

 Functional Independence Measure (FIM)7,

 Guy’s Neurological Disability Scale (GNDS)8,

 Neurological Rating Scale from the Scripps Clinic,9

 MS Rating Scale, Revised (MSRS-S).10

 Appropriate instruments from the NIH Toolbox (i.e. if the patient’s

primary impairment is motor, motor function would be assessed).11

 Appropriate instruments from the PROMIS12 or NeuroQOL.13

Denominator

Statement

All patients with a diagnosis of MS.

Denominator

Exceptions

 Patient declines to self-report and declines neurological examination.

 Patient is unable to participate in neurological examination (i.e., advanced

stage dementia, profound psychosis, neurodevelopmental disorder, brain

injury encephalopathy, or hydrocephalus.)

Supporting

Guideline &

Other

References

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Ensure all people with MS have a comprehensive review of all aspects of

their care at least once a year.”14

 “Tailor the comprehensive review to the needs of the person with MS

assessing: MS symptoms… MS disease course…”14

Measure Importance

Relationship to

Desired

Outcome

It is anticipated that by monitoring disease progression, clinicians will be able to

offer timely interventions, thereby reducing MS progression.

The annual relapse rate and Expanded Disability Status Scale (EDSS) progression

are the most commonly used clinical endpoints in disease modifying therapy

trials.3,4 A disability measure should be part of any annual assessment. The relapse

rate and disability progression are also important objective determinants for

changing MS therapy.1 Additionally, these morbidity endpoints are used in the

EDMUS database, Canadian MS Databases (BC and Ontario), NY State MS

Consortium, and NARCOMS.5,6,15

Opportunity for

Improvement

Not all patients in clinical practice have an annual validated MS scale

measurement. Clinicians cannot detect disability progression unless there is

regular assessment and comparison of assessment scores.

National

Quality Strategy

Domains

☐ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☒ Clinical Process/Effectiveness

Exception

Justification

Patients need to be willing to undergo a standardized neurological examination for

most of the MS performance scales scores to be valid.

Harmonization

with Existing

Measures

There are currently no other comparable measures in national measurement

programs or endorsed by the National Quality Forum.

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability

Type of

Measure (Check

all that apply)

☒ Process

☐ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒ Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1 Learmonth YC, Motl RW, Sandroff BM, et al. Validation of patient determined disease steps (PDDS) scale

scores in persons with multiple sclerosis. BMC Neurology 2013;13:37.

2 Cutter GR, Baier ML, Rudick RA, et al. Development of a multiple sclerosis functional composite as a clinical

trial outcome measure. Brain 1999; 122: 871–882

3 Kurtzke JF. Origin of DSS: to present the plan. Mult Scler 2007; 13:120-123.

4 Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS).

Neurology. 1983 Nov;33(11):1444-52.

5 Grimaud J, Amato MP, and Confavreux C. Design of a European multicenter study dedicated to the evaluation

of the EDMUS System: EVALUED. Mult Scler 1999; 5: 234-238.

6 Amato MP, Grimaud J, Achiti I, et. Al. European validation of a standardized clinical description of multiple

sclerosis. J Neurol 2004; 251: 1472-1480.

7 Ottenbacher KJ, Hsu Y, Granger CV, et al. The reliability of the Functional Independence Measure: a

quantitative review. Arch Phys Med Rehabil 1996;77:1226-32.

8 Sharrack B, Hughes RA. The Guy’s Neurological Disability Scale (GNDS): a new disability measure for

multiple sclerosis. Mult Scler. 199;5(4)223-233.

9 Sipe JC, Knobler RL, Braheny SL, et al. A neurologic rating scale (NRS) for use in multiple sclerosis.

Neurology 1984;34:1368-1372.

10 Wicks P, Vaughan TE, and Massagli MP. The multiple sclerosis rating scale, revised (MSRS-R): Development,

refinement, and psychometric validation using an online community, Health and Quality of Life Outcomes.

2010;10:70.

11 Hodes RJ, Insel TR, Landis SC. On behalf of the NIH Blueprint for Neuroscience Research. The NIH Toolbox:

Setting a standard for biomedical research. Neurology 2013;80(S3):S1-S92. All NIH Toolbox-related materials

12 Cella D, Riley W, Stone A, et al. Initial Adult Health Item Banks and First Wave Testing of the Patient-

Reported Outcomes Measurement Information System (PROMIS) Network: 2005-2008. J Clin Epidemiol.

2010; 63(11):1179-1194.

13 Gershon RC, Lai JS, Bode R, et al. Neuro-QOL: quality of life item banks for adults with neurological

disorders: item development and calibrations based upon clinical and general population testing. Qual Life

Res. 2012; 21(3):475-486.

14 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in

primary and secondary care. NICE Clinical Guideline 186. October 2014.

15 Vollmer TL, Ni W, Stanton S, Hadjimichael O. The NARCOMS patient registry: A resource for investigators.

Int J MS Care 1999; 1:12-15.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Fall Risk Screening for Patients with MS

Measure Description

Percentage of patients with MS who were screened for fall risk in past 12 months.

Measure Components

Numerator

Statement

Patients with MS who were screened for fall risk in past 12 months.

Definitions:

*Fall Risk Screen is not further defined, and is at provider’s discretion to allow for

flexibility to meet practice needs. The screen may include use of a validated

instrument or patient interview.

Denominator

Statement

All patients with a diagnosis of MS.

Denominator

Exceptions

None

Supporting

Guideline &

Other

References

CMS has approved the following fall risk screening measures (See Measures

Harmonization below.):

 Patients aged 65 years and older who were screened for future fall risk at

least once within 12 months. (ACO#13/NQF#0101)

 Patients aged 65 years and older with a history of falls who had a risk

assessment for falls completed within 12 months. (PQRS #154)

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Ensure all people with MS have a comprehensive review of all aspects of

their care at least once a year.”1

 “Ensure the comprehensive review is carried out by healthcare

professionals with expertise in MS and its complications. Involve

different healthcare professionals with expertise in specific areas of the

review if needed.”1

 “Tailor the comprehensive review to the needs of the person with MS

assessing: MS symptoms: mobility and balance including falls.”1

Measure Importance

Relationship to

Desired

Outcome

Falls screening and subsequent management are essential to reduce the number of

future falls.

Opportunity for

Improvement

Patients with MS are at risk for falls. A recent systematic review found 30 to 63%

of patients with MS had fallen within the past year.2 Risk factors for falling include

worse disability course, progressive course, use of ambulation aids, and poorer

performance in balance tests. A recent study found 56% of patients with MS

recorded a fall in the past 3 months in their patient diary.3

Falls screening is underutilized. Matsuda 2011 reported that 58% of persons with

MS experienced a fall in the past 6 months.4 Among that group, only 51%

reported speaking to a healthcare provider about it.4 Determining whether patients

have fallen in the past year has been found to be a strong predictor of who would

fall again.5 In a comparison of fall history, questioning on fear of fall, EDSS,

Timed 25 foot walk, and computerized balance assessment, it was found that fall

history was the best predictor of future falls, and that this is the quickest and

easiest method for assessing fall risk.6

Gillespie performed a systematic review of randomized trials to reduce falls in the

general population.7 They identified 159 RCTs comprising 79,193 patients, and

determined that exercise programs and home safety interventions were effective in

reducing fall risk. 7 Multifactorial interventions that assess an individual’s risk of

falling then recommends specific treatment based on individualized risk also

reduces falling.7

The United States Preventive Services Task Force recommends exercise or

physical therapy to prevent falls in community-dwelling adults aged 65 years or

older who are at increased risk for falls. Michael, 2010.8 In its Physician Quality

Reporting System (PQRS) Measure # 155, CMS defines a fall plan of care to

include balance, strength, and gait training.9

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☒ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☐ Clinical Process/Effectiveness

Exception

Justification

Not Applicable

Harmonization

with Existing

Measures

Existing measures (e.g., ACO Measure #13/NQF #0101, PQRS Measure #154)

focus on individuals aged 65 and older. All patients with MS should be screened

for fall risk, not just those aged 65 years and older, and as a result this measure was

developed to capture screening for this population.

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability

Type of

Measure (Check

all that apply)

☒Process

☐ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in

primary and secondary care. NICE Clinical Guideline 186. October 2014

2 Giannì C, Prosperini L, Jonsdottir J, Cattaneo D. A systematic review of factors associated with accidental falls

in people with multiple sclerosis: a meta-analytic approach. Clin Rehabil. 2014 Feb 25;28(7):704-716.

3 Nilsagård Y, Gunn H, Freeman J, et al. Falls in people with MS-an individual data meta-analysis from studies

from Australia, Sweden, United Kingdom and the United States. Mult Scler. 2014 Jun 16.;1-9.

4 Matusda, PN, Shumway-Cook A, Bamer AM, et al. Falls in multiple sclerosis. PM R 2011(7):624-632.

5 Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86.

6 Cameron MH, Thielman E, Mazumder R, et al. Predicting falls in people with multiple sclerosis: fall history is

as accurate as more complex measures Mult Scler Int. 2013; 2013: Article ID 496325. 7p.

7 Gillespie LD, Robertson MC, Gillespie WJ, Sherrington C, Gates S, Clemson LM, Lamb SE. Interventions for

preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012 Sep

12;9:CD007146.

8 Michael YL, Whitlock EP, Lin JS, Fu R, O'Connor EA, Gold R; US Preventive Services Task Force. Primary

care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S.

Preventive Services Task Force. Ann Intern Med. 2010 Dec 21;153(12):815-25.

9 Centers for Medicare & Medicaid Services. Physician Quality Reporting System Measure Codes found at:

http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/MeasuresCodes.html

Accessed on July 28, 2014.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Bladder Infections for Patients with MS

Measure Description

Percentage of patients with MS who have had a bladder infection in past 12 months.

Note: Please see page 10 for further discussion of risk adjustment and stratification. Measure may be

used for accountability at the system or accountable care organization level if the MS populations being

compared are similar in demographics, socioeconomic status and the prevalence of comorbid

conditions.

Measure Components

Numerator

Statement

Patients with MS who have had a documented bladder infection in the past 12

months.

Denominator

Statement

All patients with a diagnosis of MS.

Denominator

Exceptions

 Documentation of an indwelling catheter.

 Documentation of diverting urostomy.

Supporting

Guideline &

Other

References

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Assess for infection and assist in management strategies to reduce risk of

infection, stone formation, or worsening of neurologic condition (Level

3).”1

 “Ensure all people with MS have a comprehensive review of all aspects of

their care at least once a year.”1

 “Tailor the comprehensive review to the needs of the person with MS

assessing: MS symptoms: … bladder, bowel and sexual function…”2

Measure Importance

Relationship to

Desired

Outcome

The desired outcome is to reduce the number of bladder infections. The measure

focuses attention on bladder infections and creates an incentive to take measures

needed to prevent them. This measure requires internal benchmarking for quality

improvement efforts, and it is anticipated in future measurement updates if the

measure is retained due to a continued gap in care that benchmarking data for

providers will be included. (e.g., bladder infection rates will be reduced by a

certain percentage rate over time.)

Opportunity for

Improvement

Bladder infections occur in up 20% of patients with MS3 and are commonly

present in patients with relapses.4 Recognition of neurogenic bladder and proper

management of bladder dysfunction can reduce the incidence of infection.

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☒ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☐ Clinical Process/Effectiveness

Exception

Justification

 Patients with indwelling catheters are likely to have chronic bacteriuria

due to bacterial colonization making implementation of the measure

difficult.

 Most patients with urostomies do not have functioning bladders

Harmonization

with Existing

Measures

There are currently not comparable measures in national measurement programs or

endorsed by the National Quality Forum.

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability

Type of

Measure (Check

all that apply)

☐Process

☒ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1 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.

2 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in

primary and secondary care. NICE Clinical Guideline 186. October 2014.

3 Manach A, Motsko SP, Haag-Molkenteller C, et al. Epidemiology and healthcare utilization of neurogenic

bladder patients in US claims database. Neurourol Urodyn 2011; 30: 395-401.

4 Mahadeva A, Tarosescu R, Gran B. Urinary tract infections in multiple sclerosis: underdiagnosed and

undertreated? Am J Clin Exp Immunol 2014; 3: 57-67.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Exercise and Appropriate Physical Activity Counseling for Patients with MS

Measure 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.

Measure Components

Numerator

Statement

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 consultation1

Denominator

Statement

All patients with a diagnosis of MS.

Denominator

Exceptions

None**

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

on appropriate range of motion and activity.

Supporting

Guideline &

Other References

The following evidence statements are quoted verbatim from the referenced

clinical guidelines:

 “Evidence-based treatment interventions for mobility optimization

include exercise promotion (Level 1).”2

 “Encourage participation in a regular pattern of exercise to improve mood

(Level 1).”2

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

exercise may have beneficial effects on their MS and does not have any

harmful effects on their MS.”3

 “Ensure all people with MS have a comprehensive review of all aspects of

their care at least once a year.”3

 “Tailor the comprehensive review to the needs of the person with MS

assessing: General health: …exercise…”3

Measure Importance

Relationship to

Desired

Outcome

Increased rates of physical activity and exercise improve the physical functioning

levels and quality of life for patients with MS.4

Opportunity for

Improvement

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

inactive.5,6 The Work Group encourages referral to rehabilitation services,

including physical therapy, when clinically appropriate given the evidence

supporting improved outcomes for patients.7-9

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☒ Clinical Process/Effectiveness

Exception

Justification

Not Applicable

Harmonization

with Existing

Measures

There are currently not comparable measures in national measurement

programs or endorsed by the National Quality Forum.

Measure Designation

Measure Purpose

(Check all that

apply)

☒ Quality improvement

☒ Accountability

Type of Measure

(Check all that

apply)

☒Process

☐ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

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

2 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.

3 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in

primary and secondary care. NICE Clinical Guideline 186. October 2014.

4 American College of Sports Medicine: ACSM's Resource Manual for Guidelines for Exercise Testing and

Prescription, 6th edition edn. Baltimore, MD: Lippincott Williams & Wilkins; 2010.

5 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.

6 Motl RW, McAuley E, Snook EM. Physical activity and multiple sclerosis: a meta-analysis. Mult Scler 2005;

11(4):459-463.

7 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.

8 Rietberg MB, Brooks D, Uitdehaag BMJ, Kwakkel G. Exercise therapy for multiple sclerosis. Cochrane

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

9 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.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New

Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-

New or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Fatigue Outcome for Patients with MS

Measure Description

Percentage of patients with MS whose most recent score indicates results are maintained or improved

on a validated fatigue rating instrument* for patients with MS in past 12 months.

Note: Please see page 10 for further discussion of risk adjustment and stratification. Measure may be

used for accountability at the system or accountable care organization level if the MS populations being

compared are similar in demographics, socioeconomic status and the prevalence of comorbid

conditions.

Measure Components

Numerator

Statement

Patients with MS whose most recent score indicates results are maintained or

improved on a validated fatigue rating instrument* for patients with MS in past 12

months.

*Validated fatigue rating instruments include the Fatigue Severity Scale (FSS),1-3

Fatigue Impact Scale,4 MS Specific Fatigue Severity Scale,5,6 Modified Fatigue

Impact Scale,7 or Unidimensional Fatigue Impact Scale8

Denominator

Statement

All patients with a diagnosis of MS.

Denominator

Exceptions

 Patients unable or declines to complete a fatigue questionnaire (i.e.,

advanced stage dementia, profound psychosis, neurodevelopmental

disorder, brain injury encephalopathy, or hydrocephalus.)

 Comorbid medical condition causing fatigue (i.e., Systemic inflammatory

condition, cardiac condition, renal failure, pulmonary condition, or sleep

apnea.)

Supporting

Guideline &

Other

References

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.”9

 “Explain that MS-related fatigue may be precipitated by heat, overexertion

and stress or may be related to the time of day.”9

 “Nurses should be aware of and assess for secondary causes of fatigue to

include depression, medication side effects, pain, and sleep disorders

(Level 2). Nurses should educate and counsel patients regarding energy

conservation strategies, including the role of body temperature control

(Level 2). The nurse should be aware of the optimal timing of medication

administration to enhance energy level and to avoid interrupting sleep

(Level 3).”10

Measure Importance

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.

Opportunity for

Improvement

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

level of daily functioning.8 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.

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☒ Clinical Process/Effectiveness

Exception

Justification

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

 Diseases other than MS can cause fatigue so patients with other fatigue

causing diseases are excluded from the MS measure

Harmonization

with Existing

Measures

There are currently no other comparable fatigue measures in national measurement

programs or endorsed by the National Quality Forum.

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability

Type of

Measure (Check

all that apply)

☐Process

☒ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☐ Individual Provider

☐ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1 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.

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

Elsevier Science; 2003.

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

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

4 Fisk JD, Ritvo PG, Ross L, et al. Measuring the functional impact of fatigue: initial validation of the Fatigue

Impact Scale. Clin Infect Dis 1994;18(1):S79-S83.

5 Kos D., Kerckhofs E., Nagels G, et al. Assessing fatigue in multiple sclerosis: Dutch modified fatigue impact

scale. Acta Neurologica Belgica 2003;103(4):185–191.

6 Kos D, Nagels G, D’Hooghe MB, et al. A rapid screening tool for fatigue impact in multiple sclerosis. BMC

Neurology 2006, 6:27

7 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.

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

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

9 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in

primary and secondary care. NICE Clinical Guideline 186. October 2014.

10 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.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Cognitive Impairment Testing for Patients with MS

Measure Description

Percentage of patients 18 years and older with MS who were tested* for cognitive impairment in the

past 12 months.

Measure Components

Numerator

Statement

Patients with MS aged 18 years and older were tested* for cognitive impairment at

least once in past 12 months.

Definitions:

* Tested is defined as administering either:

 Brief International Assessment of Cognition for MS (BICAMS),1

 Symbol Digit Modalities Test (SDMT),2

 MS Neuropsychological Screening Questionnaire (MSNQ) Informant,3

 Verbal fluency (phonemic and semantic),4

 Paced Auditory Serial Addition Test (PASAT),3

 Rao Brief Repeatable Neuropsychological Battery (BRNB),3

 Minimal Assessment of Cognitive Function in MS (MACFIMS),3 or

 PROMIS.5

 Referral for formal neuropsychological testing where clinically appropriate

would also satisfy measure.

Denominator

Statement

All patients aged 18 years or older with a diagnosis of MS.

Denominator

Exceptions

 Patient declines or is not able to participate in a cognitive assessment,

including those at end of life, comatose, or delirious.

 Patient currently receiving treatment to address cognitive impairment.

Supporting

Guideline &

Other

References

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Assess and offer treatment to people with MS and evidence of memory

and cognitive problems for anxiety, depression, difficulty in sleeping and

fatigue.”8

 “Nurses should work with the patient, care partner, and other members of

the interdisciplinary team to develop an appropriate cognitive management

program and reevaluate on an ongoing basis (Level 3). The nurse should

screen for factors that could increase cognitive problems such as

medications, sleep disturbance, inadequately treated pain, and other

untreated symptoms (Level 2). Nurses need to recognize and acknowledge

the distressing nature of cognitive deficits (Level 3). Patients should be

provided with verbal and written instructions regarding the need to reduce

distractions and implement safety measures (Level 3).”9

 “Ensure all people with MS have a comprehensive review of all aspects of

their care at least once a year.”8

 “Tailor the comprehensive review to the needs of the person with MS

assessing: MS symptoms: …cognitive symptoms…”8

 “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.”8

 “Talk to people with MS and their family members or carers about the

possibility that the condition might lead to cognitive problems.”8

 “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.”8

Measure Importance

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.

Opportunity for

Improvement

43-70% of people with MS have reported cognitive impairments.7 Clinicians

cannot detect cognitive impairment unless there is regular assessment.

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☒ Clinical Process/Effectiveness

Exception

Justification

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

to be valid.

Harmonization

with Existing

Measures

There are no currently endorsed cognitive impairment quality measures; current

endorsed quality measures focus on dementia assessment. A measure is needed to

address the opportunity for improvement specific to the cognitive impairments

faced by the MS population.

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability for Health System or Plans only

Type of

Measure (Check

all that apply)

☒Process

☐ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

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 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.

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 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.

6 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.

7 Langdon DW, Amato MP, Boringa J, et al. Recommendations for a Brief International Cognitive Assessment

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

8 National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in

primary and secondary care. NICE Clinical Guideline 186. October 2014.

9 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.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Clinical Depression Screening for Patients with MS

Measure Description

Percentage of patients aged 12 years and older with MS who were screened for clinical depression

using an age appropriate standardized depression screening tool* at least once in past 12 months.

Measure Components

Numerator

Statement

Patients aged 12 years and older with MS who were screened for clinical

depression using an age appropriate standardized depression screening tool* at

least once in past 12 months.

*Depression screening tool: Clinicians should consider use of validated

instruments such as the:

 Beck Depression Inventory (BDI) or BDI II,

 Patient Health Questionnaire (PHQ-9), (PHQ-A), or (PHQ-2),

 MS Depression Rating Scale,

 Center for Epidemiological Studies-Depression Revised (CESD-R),

 Hospital Anxiety and Depression Scale (HADS),

 General Health Questionnaire (GHQ),

 2 Question Screen,

 Neuro QOL Depression Bank. 1-6

Note: Currently no validated depression screening tools based on caregiver report

are known.

Denominator

Statement

All patients aged 12 years or older with a diagnosis of MS.

Denominator

Exceptions

Patients who are unable or decline to complete screening instrument.

Supporting

Guideline &

Other

References

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Clinicians may consider the Beck Depression Inventory and a 2-question

tool to screen for depressive disorders and the General Health

Questionnaire to screen for broadly defined emotional disturbances (Level

C).”1

 “Evidence is insufficient to support/refute the use of other screening tools,

the possibility that somatic/neurovegetative symptoms affect these tools’

accuracy, or the use of diagnostic instruments or clinical evaluation

procedures for identifying psychiatric disorders in MS (Level U).”1

 “Ensure all people with MS have a comprehensive review of all aspects of

their care at least once a year.”2

 “Tailor the comprehensive review to the needs of the person with MS

assessing: MS symptoms:: …depression and anxiety…”2

 “Mood Dysregulation: Nurses should work with the patient, care partner,

and other members of the interdisciplinary team to manage depression

appropriately (Level 2). Other roles are to assist patients and care partners

to adjust to changes involved in living with MS (Level 2); identify the

physical, emotional, spiritual, and educational needs of the patient and

family (Level 2); reinforce the importance of medication regimen and be

aware of medication side effects (Level 2); be alert to cues related to mood

changes and treatment outcomes (Level 2); and encourage participation in

a regular pattern of exercise to improve mood (Level 1).”3

Measure Importance

Relationship to

Desired Outcome

Screening is the first step to improved recognition and treatment of depression in

MS patients, and to decrease rates of affective symptoms in the MS patient

population.

Opportunity for

Improvement

MS is frequently associated with depression, and is currently under diagnosed

and treated.4,7 Evidence of under diagnosis of depression in MS patients makes

screening vital to identifying those in need of treatment.

National Quality

Strategy Domains

☐ Patient and Family Engagement

☐ Patient Safety

☒Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☐ Clinical Process/Effectiveness

Exception

Justification

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

scores to be valid.

Harmonization

with Existing

Measures

Several NQF endorsed measures exist that address depression and treatment

adherence. These measures include Antidepressant Medication Management,

Child and Adolescent Major Depressive Disorders: Diagnostic Evaluation, Adult

Major Depressive Disorder: Suicide Risk Assessment, and Depression Response

at Twelve Months – Progress Towards Remission. It was determined a separate

measure assessing screening rates was required specific to the MS population

given the existing gap in care, as well as the need to use validated screening

tools specific to the MS population.

Measure Designation

Measure Purpose

(Check all that

apply)

☒ Quality improvement

☒ Accountability

Type of Measure

(Check all that

apply)

☒Process

☐ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☒ Individual Provider

☒ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1. Minden SL, Feinstein A, Kalb RC, et al. Evidence-based Guideline: Assessment and Management of

Psychiatric Disorders in Individuals with MS: Report of the Guideline Development Subcommittee of

the American Academy of Neurology. Neurology 2014; 82:1-8.

2. National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis

in primary and secondary care. NICE Clinical Guideline 186. October 2014.

3. 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.

4. Fargoso YD, Adoni T, Anacleto, et al. Recommendations on diagnosis and treatment of depression in

patients with multiple sclerosis. Pract Neurol 2014; 0:1-6.

5. Verdier-Taillerfer MH, Gourlet V, Fuhrer R, et al. Psyhometric properties of the Center for

Epidemiologic Studies- Depression scale in multiple sclerosis. Neuroepidemiology 2001; 20(4):262-267.

6. Gershon RC, Lai JS, Bode R, et al. Neuro-QOL: quality of life item banks for adults with neurological

disorders: item development and calibrations based upon clinical and general population testing. Qual

Life Res. 2012; 21(3):475-486.

7. Till C, Udler E, Ghassemi R, et al. Factors associated with emotional and behavioral outcomes in

adolescents with multiple sclerosis. Mult Scler 2012;18(8):1170-80.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Depression Outcome for Patients with MS

Measure Description

Percentage of patients aged 12 years and older with MS whose most recent score indicates results are

maintained or improved on a validated depression screening instrument* for patients with MS in past

12 months.

Note: Please see page 10 for further discussion of risk adjustment and stratification. Measure may be

used for accountability at the system or accountable care organization level if the MS populations being

compared are similar in demographics, socioeconomic status and the prevalence of comorbid

conditions.

Measure Components

Numerator

Statement

Patients aged 12 years and older with MS whose most recent score indicates results

are maintained or improved on a validated depression screening instrument* for

patients with MS in past 12 months.

*Depression screening tool: Clinicians should consider use of validated

instruments such as the:

 Beck Depression Inventory (BDI) or BDI II,

 Patient Health Questionnaire (PHQ-9), (PHQ-A), or (PHQ-2),

 MS Depression Rating Scale,

 Center for Epidemiological Studies-Depression Revised (CESD-R),

 Hospital Anxiety and Depression Scale (HADS),

 General Health Questionnaire (GHQ),

 2 Question Screen,

 Neuro QOL Depression Bank. 1-6

Denominator

Statement

All patients aged 12 years or older with a diagnosis of MS.

Denominator

Exceptions

Patients who are unable or decline to complete screening instrument.

Supporting

Guideline &

Other

References

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Clinicians may consider the Beck Depression Inventory and a 2-question

tool to screen for depressive disorders and the General Health

Questionnaire to screen for broadly defined emotional disturbances (Level

C).”1

 “Evidence is insufficient to support/refute the use of other screening tools,

the possibility that somatic/neurovegetative symptoms affect these tools’

accuracy, or the use of diagnostic instruments or clinical evaluation

procedures for identifying psychiatric disorders in MS (Level U).”1

 “For individuals with MS, a 16-week program of individual T-CBT is

possibly effective and may be considered in treating depressive symptoms

(Level C).”1

 “Mood Dysregulation: Nurses should work with the patient, care partner,

and other members of the interdisciplinary team to manage depression

appropriately (Level 2). Other roles are to assist patients and care partners

to adjust to changes involved in living with MS (Level 2); identify the

physical, emotional, spiritual, and educational needs of the patient and

family (Level 2); reinforce the importance of medication regimen andbe

aware of medication side effects (Level 2); be alert to cues related to mood

changes and treatment outcomes (Level 2); and encourage participation in

a regular pattern of exercise to improve mood (Level 1).”2

Measure Importance

Relationship to

Desired

Outcome

Reduction of depressive symptoms is the desired outcome for MS patients.

Opportunity for

Improvement

There is evidence of inadequate recognition and treatment of depression in MS

patients.3,4

National Quality

Strategy

Domains

☐ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☒ Clinical Process/Effectiveness

Exception

Justification

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

to be valid.

Harmonization

with Existing

Measures

Several NQF endorsed measures exist that address depression and treatment

adherence. These measures include Antidepressant Medication Management,

Child and Adolescent Major Depressive Disorders: Diagnostic Evaluation, Adult

Major Depressive Disorder: Suicide Risk Assessment, and Depression Response at

Twelve Months – Progress Towards Remission. It was determined a separate

measure assessing screening rates was required specific to the MS population

given the existing gap in care. Efforts were made to harmonize this measure with

Depression Response at Twelve Months (MN Community Measurement); this

measure allows for clinicians to use multiple screening tools beyond the PHQ-9.

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability

Type of

Measure (Check

all that apply)

☐Process

☒ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☐ Individual Provider

☐ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1. Minden SL, Feinstein A, Kalb RC, et al. Evidence-based Guideline: Assessment and Management of

Psychiatric Disorders in Individuals with MS: Report of the Guideline Development Subcommittee of

the American Academy of Neurology. Neurology 2014; 82:1-8.

2. 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.

3. Fargoso YD, Adoni T, Anacleto, et al. Recommendations on diagnosis and treatment of depression in

patients with multiple sclerosis. Pract Neurol 2014; 0:1-6.

4. Till C, Udler E, Ghassemi R, et al. Factors associated with emotional and behavioral outcomes in

adolescents with multiple sclerosis. Mult Scler 2012;18(8):1170-80.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Maintained or Improved Baseline Quality of Life for Patients with MS

Measure Description

Percentage of patients with MS whose most recent score indicates results are maintained or improved

on an age appropriate Quality of Life tool* in past 12 months.

Note: Please see page 10 for further discussion of risk adjustment and stratification. Measure may be

used for accountability at the system or accountable care organization level if the MS populations being

compared are similar in demographics, socioeconomic status and the prevalence of comorbid

conditions.

Measure Components

Numerator

Statement

Patients with MS whose most recent score indicates results are maintained or

improved on an age appropriate Quality of Life tool* in past 12 months.

*Suggested MS-specific QOL tools include the Multiple Sclerosis Impact Scale

(MSIS-29)1,2, Multiple Sclerosis Quality of Life (MS QOL-54)3, Patient-Reported

Outcome Indices for Multiple Sclerosis (PRIMUS)4,5, Multiple Sclerosis

International Quality of Life (MusiQOL)6, Functional Assessment of Multiple

Sclerosis (FAMS)7, and EuroQoL (EQ-5D)8. Alternatively, NeuroQOL or the NIH

Toolbox may be used.9,10

Denominator

Statement

All patients with a diagnosis of MS.

Denominator

Exceptions

Patients who are unable or decline to complete quality of life instrument.

Supporting

Guideline &

Other

References

Following evidence statements are quoted verbatim from the referenced clinical

guidelines:

 “Use the local-language version of the multiple sclerosis international

quality of life (MusiQoL) questionnaire to assess patient QoL every12

months.”11

 “Nurses should facilitate treatment and symptom management, promote

and enhance function, and support a quality of life (QOL) of adults with

MS and their family-care partners that is wellness focused (Level 3).”12

Measure Importance

Relationship to

Desired

Outcome

Improving QOL is a desired outcome for all patients with MS. MS can diminish

QOL given MS symptoms which impair a person’s ability to work and engage in

social activities.

Opportunity for

Improvement

QOL assessment is necessary as it can significantly impact adherence to

medications and affect physical rehabilitation.13 Despite the relationship between

QOL and treatment adherence, there remains a gap in treatment as clinicians fail to

address QOL.13 Measuring QOL and monitoring for maintenance or improvement

is expected to result in improved QOL assessment and prompt timely interventions

for patient identified concerns.

National Quality

Strategy

Domains

☒ Patient and Family Engagement

☐ Patient Safety

☐Care Coordination

☐ Population/Public Health

☐ Efficient Use of Healthcare Resources

☐ Clinical Process/Effectiveness

Exception

Justification

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

to be valid.

Harmonization

with Existing

Measures

Existing endorsed measures assess quality of life as a process measure for a select

group of individuals and are not generalizable to the MS population. (e.g.,

receiving dialysis, (Assessment of Health-related Quality of Life

http://www.qualityforum.org/QPS/0260) family receiving hospice

(http://www.qualityforum.org/QPS/0208))

Measure Designation

Measure

Purpose (Check

all that apply)

☒ Quality improvement

☒ Accountability

Type of

Measure (Check

all that apply)

☐Process

☒ Outcome

☐ Structure

Level of

Measurement

(Check all that

apply)

☐ Individual Provider

☐ Practice

☒ System or Health Plan

Care Setting

(Check all that

apply)

☒ Outpatient

☐ Inpatient

☐ Emergency Departments and Urgent Care

Data Source

(Check all that

apply)

☒ Electronic health record (EHR) data

☒Administrative Data/Claims

☐ Chart Review

☒ Registry

References

1 Hobart J, Lamping D, Fitzpatrick R, et al. The Multiple Sclerosis Impact Scale (MSIS-29) A new patient-based

outcome measure. Brain 2001;124(5):962-973.

2 Multiple Sclerosis Impact Scale (MSIS-29) Available online at:

http://www.biomedcentral.com/content/supplementary/1471-2377-8-2-s1.doc Accessed on July 28, 2014.

3 Vickery BG. Multiple Sclerosis Quality of Life (MSQOL)-54 Instrument. Available online at:

http://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/MSQOL54_995.pdf

Accessed on July 28, 2014.

4 Doward LC, McKenna SP, Meads DM, et al. The development of Patient Reported Outcome Indices for

Multiple Sclerosis (PRIMUS). Mult Scler 2009;15:1092–102.

5 McKenna SP, Doward LC, Twiss J, et al. International Development of the Patient-Reported Outcome Indices

for Multiple Sclerosis (PRIMUS). Value in Health 2010; 13(8):946-951.

6 Simeoni MC, Auquier P, Fernandez O, et al. Validation of the Multiple Sclerosis International Quality of Life

questionnaire. Multiple Sclerosis 2008;14(2):219-230.

7 Cella DF, Dineen K, Arnason B, et al. Validation of the functional assessment of multiple sclerosis quality of

life instrument. Neurology 1996;47(1):129-139.

8 Putzki N, Fischer J, Gottwald K., et al.Quality of Life in 1000 patients with early relapsing-remitting multiple

sclerosis. European Journal of Neurology 2009;16:713-720.

9 Gershon RC, Lai JS, Bode R, et al. Neuro-QOL: quality of life item banks for adults with neurological

disorders: item development and calibrations based upon clinical and general population testing. Qual Life

Res. 2012; 21(3):475-486.

10 Hodes RJ, Insel TR, Landis SC. On behalf of the NIH Blueprint for Neuroscience Research. The NIH Toolbox:

Setting a standard for biomedical research. Neurology 2013;80(S3):S1-S92. All NIH Toolbox-related materials

11 Al-Tahan ARM, Al-Jumah MA, Bohlega S, et al. The importance of quality-of-life assessment in the

management of patients with multiple sclerosis Recommendations from the Middle East MS Advisory Group.

Neurosciences 2011; 16(2):109-113.

12 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.

13 Zwibel HL and Smrtka J. Improving Quality of Life in Multiple Sclerosis: An Unmet Need. Am J Manag Care.

2011;17:S139-S145.

Technical Specifications: Electronic Health Record (EHR) Data

The AAN is in the process of creating code value sets and the logic required for electronic capture of

the quality measures with EHRs. A listing of the quality data model elements, code value sets, and

measure logic (through the CMS Measure Authoring Tool) for each of the MS measures will be made

available at a later date.

Technical Specifications: Administrative Data (Claims)

Administrative claims data collection requires users to identify the eligible population (denominator)

and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a

rate based on all patients in a given practice for whom data are available and who meet the eligible

population/ denominator criteria.

Denominator

(Eligible

Population)

ICD-9 Code

ICD-10 Code

340 Multiple Sclerosis

G35 Multiple Sclerosis

Disseminated multiple sclerosis

Generalized multiple sclerosis

Multiple sclerosis NOS

Multiple sclerosis of brain stem

Multiple sclerosis of cord

AND

CPT E/M Service Code:

99201, 99202, 99203, 99204, 99205 (Office or other outpatient visit-New Patient);

99211, 99212, 99213, 99214, 99215 (Office or other outpatient visit-Established

Patient);

99241, 99242, 99243, 99244, 99245 (Office or Other Outpatient Consultation-New

or Established Patient);

97001 (Physical therapy evaluation);

97002 ( Physical therapy re-evaluation);

97003 (Occupational therapy evaluation);

97004 (Occupational therapy re-evaluation)

Contact Information

For more information about quality measures please contact:

American Academy of Neurology

201 Chicago Avenue

Minneapolis, MN 55415

Phone: (612) 928-6100

Fax: 612-454-2744

quality@aan.com

Kantarci O, and Wingerchuk D. Epidemiology and natural history of multiple sclerosis: new insights. Current

Opinion in Neurology 2006;19:248-254

Zwibel H and Smrtka J. Improving Quality of Life in MS: an Unmet Need. American Journal of Managed Care

2011;17:S139-145.

Multiple Sclerosis International Federation. Atlas of MS 2013. 2013 28p.

World Health Organization. Neurological disorders: a public health approach. 2007.

National Multiple Sclerosis Society. Challenges of epidemiological studies website.

Noonan CW, Williamson DM, Henry JP, Indian R, Lynch SG, Neuberger JS, et al. The prevalence of multiple

sclerosis in 3 US communities. Prev Chronic Dis 2010;7(1):A12. Available at:

http://www.cdc.gov/pcd/issues/2010/jan/08_0241.htm. Accessed March 11, 2014.

Compston A, Coles A. Multiple sclerosis. Lancet 2008; 372: 1502-1517.

Adelman G., Rane SG, Villa KF. The cost burden of multiple sclerosis in the United States: a systematic review of

the literature. Journal of Medical Economics 2013; 16(5):639-647.

Minden SL, Feinstein A, Kalb RC, et al. Evidence-based Guideline: Assessment and Management of Psychiatric

Disorders in Individuals with MS: Report of the Guideline Development Subcommittee of the American Academy

of Neurology. Neurology 2014; 82:1-8.

Marriott JJ, Miyasaki JM, Gronseth G, O'Connor PW, Therapeutics and Technology Assessment Subcommittee of

the American Academy of Neurology. Evidence report: the efficacy and safety of mitoxantrone (Novantrone) in the

treatment of multiple sclerosis: Report of the Therapeutics and Technology Assessment Subcommittee of the

American Academy of Neurology. Neurology. 2010;74(18):1463-1470.

Neutralizing antibodies to interferon beta: Assessment of their clinical and radiographic impact: An evidence

report. Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of

Neurology. Neurology. 2007;68:977-984.

Cortese I, Chaudhry V, So YT, Cantor F, Cornblath DR, Rae-Grant A. Evidence-based guideline update:

Plasmapheresis in neurologic disorders: report of the Therapeutics and Technology Assessment Subcommittee of the

American Academy of Neurology. Neurology. 2011;76(3):294-300.

Scott TF, Frohman EM, De Seze J, Gronseth GS, Weinshenker BG. Evidence-based guideline: clinical evaluation

and treatment of transverse myelitis: report of the Therapeutics and Technology Assessment Subcommittee of the

American Academy of Neurology. Neurology. 2011 Dec 13;77(24):2128-34.

Practice parameter: The usefulness of evoked potentials in identifying clinically silent lesions in patients with

suspected multiple sclerosis (an evidence-based review): Report of the Quality Standards Subcommittee of the

American Academy of Neurology. Neurology. 2000 54;1720-1725.

Yadav V, Bever CT, Bowen J, et al. Summary of evidence-based guideline: Complementary and alternative

medicine in multiple sclerosis. Report of the Guideline Development Subcommittee of the American Academy of

Neurology. Neurology 2014; 82(12):1083-1092.

National Institute for Health and Care Excellence. Multiple sclerosis: management of multiple sclerosis in primary

and secondary care. NICE Clinical Guideline 186. October 2014.

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.

Soelberg Sørensen P, Deisenhammer F, Duda P, et al. Use of anti-interferon beta antibody measurements in

multiple sclerosis. In: Gilhus NE, Barnes MP, Brainin M, editor(s). European handbook of neurological

management. 2nd ed. Vol. 1. Oxford (UK): Wiley-Blackwell; 2011. p. 64-74.

Sellebjerg F, Barnes D, Filippini G, et al. Acute relapses of multiple sclerosis. In: Gilhus NE, Barnes MP, Brainin

M, editor(s). European handbook of neurological management. 2nd ed. Vol. 1. Oxford (UK): Wiley-Blackwell;

2011. p. 410-419.

National Institute for Health and Clinical Excellence (NICE). Fingolimod for the treatment of highly active

relapsing-remitting multiple sclerosis. London (UK): National Institute for Health and Clinical Excellence (NICE);

2012 Apr. 55 p. (Technology appraisal guidance; no. 254).

Consortium of Multiple Sclerosis Centers. Consortium of MS Centers MRI Protocol for the Diagnosis and

Follow-up of MS 2009 Revised Guidelines.

Al-Tahan ARM, Al-Jumah MA, Bohlega S, et al. The importance of quality-of-life assessment in the

management of patients with multiple sclerosis Recommendations from the Middle East MS Advisory Group.

Neurosciences 2011; 16(2):109-113.

http://www.merriam-webster.com/medical/consult

http://www.merriam-webster.com/medical/counsel

http://www.merriam-webster.com/dictionary/educate

http://www.merriam-webster.com/medical/refer

http://www.merriam-webster.com/medical/screen

Cheng EM, Crandall CJ, Bever CT, et al. Quality indicators for multiple sclerosis. Multiple Sclerosis

2010:16(8):970-980.

SET 10 Appendix E 1

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