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Measure: CMS50

Closing the Referral Loop: Receipt of Specialist Report

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS50v9 2021 9.2.000 Closing the Referral Loop: Receipt of Specialist Report
CMS50v8 2020 8.0.000 Closing the Referral Loop: Receipt of Specialist Report
CMS50v7 2019 7.1.000 Closing the Referral Loop: Receipt of Specialist Report
CMS50v6 2018 6.0.000 Closing the Referral Loop: Receipt of Specialist Report
CMS50v5 2017 5.0.000 Closing the Referral Loop: Receipt of Specialist Report

Description

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Guidance

The provider who refers the patient to another provider is the provider who should be held accountable for the performance of this measure. The provider to whom the patient was referred should be the same provider that sends the report. If there are multiple referrals for a patient during the measurement period, use the first referral. The consultant report that will fulfill the referral should be completed after the referral, and should be related to the referral for which it is attributed. If there are multiple consultant reports received by the referring provider which pertain to a particular referral, use the first consultant report to satisfy the measure. Eligible professionals or eligible clinicians reporting on this measure should note that all data for the reporting year is to be submitted by the deadline established by CMS. Therefore, eligible professionals or eligible clinicians who see patients towards the end of the reporting period (ie, December in particular), should communicate the consultant report as soon as possible in order for those patients to be counted in the measure numerator. Communicating the report as soon as possible will ensure the data is included in the submission to CMS.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationNumber of patients, regardless of age, who were referred by one provider to another provider, and who had a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsNone
NumeratorNumber of patients with a referral, for which the referring provider received a report from the provider to whom the patient was referredWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone

Details

Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS50v6 50 2018 6.0.000 Not Applicable f58fc0d6-edf5-416a-8d29-79afbfd24dea
Steward Developer Endorsed By
National Committee for Quality Assurance Centers for Medicare & Medicaid Services (CMS)
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation

None

Improvement Notation

A higher score indicates better quality

Rationale

Problems in the outpatient referral and consultation process have been documented, including lack of timeliness of information and inadequate provision of information between the specialist and the requesting physician (Gandhi, 2000; Forrest, 2000; Stille, 2005). In a study of physician satisfaction with the outpatient referral process, Gandhi et al. (2000) found that 68% of specialists reported receiving no information from the primary care provider prior to referral visits, and 25% of primary care providers had still not received any information from specialists 4 weeks after referral visits. In another study of 963 referrals (Forrest, 2000), pediatricians scheduled appointments with specialists for only 39% and sent patient information to the specialists in only 51% of the time. In a 2006 report to Congress, MedPAC found that care coordination programs improved quality of care for patients, reduced hospitalizations, and improved adherence to evidence-based care guidelines, especially among patients with diabetes and CHD. Associations with cost-savings were less clear; this was attributed to how well the intervention group was chosen and defined, as well as the intervention put in place. Additionally, cost-savings were usually calculated in the short-term, while some argue that the greatest cost-savings accrue over time (MedPAC, 2006). Improved mechanisms for information exchange could facilitate communication between providers, whether for time-limited referrals or consultations, on-going co-management, or during care transitions. For example, a study by Branger et al. (1999) found that an electronic communication network that linked the computer-based patient records of physicians who had shared care of patients with diabetes significantly increased frequency of communications between physicians and availability of important clinical data. There was a 3-fold increase in the likelihood that the specialist provided written communication of results if the primary care physician scheduled appointments and sent patient information to the specialist (Forrest, 2000). Care coordination is a focal point in the current health care reform and our nation's ambulatory health information technology (HIT) framework. The National Priorities Partnership recently highlighted care coordination as one of the most critical areas for development of quality measurement and improvement (NPP, 2008).

Clinical Recommendation Statement

None

Definition

Referral: A request from one physician or other eligible provider to another practitioner for evaluation, treatment, or co-management of a patient's condition. This term encompasses referral and consultation as defined by Centers for Medicare and Medicaid Services.

Transmission Format

TBD

Applicable Value Sets

Category Value Set OID
Communication: From Provider to Provider Consultant Report 2.16.840.1.113883.3.464.1003.121.12.1006
Encounter, Performed Face-to-Face Interaction 2.16.840.1.113883.3.464.1003.101.12.1048
Encounter, Performed Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed Ophthalmological Services 2.16.840.1.113883.3.526.3.1285
Encounter, Performed Preventive Care - Established Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1024
Encounter, Performed Preventive Care Services - Established Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed Preventive Care Services-Initial Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed Preventive Care- Initial Office Visit, 0 to 17 2.16.840.1.113883.3.464.1003.101.12.1022
Patient Characteristic Ethnicity Ethnicity 2.16.840.1.114222.4.11.837
Patient Characteristic Payer Payer 2.16.840.1.114222.4.11.3591
Patient Characteristic Race Race 2.16.840.1.114222.4.11.836
Patient Characteristic Sex ONC Administrative Sex 2.16.840.1.113762.1.4.1

References

Branger, P. J., Van't Hooft, A., Van Der Wouden, J. C., Moorman, P. W., and Van Bemmel, J. H. (1999). Shared care for diabetes: supporting communication between primary and secondary care. International Journal of Medical Informatics 53(2-3), 133-142.
Forrest, C. B., Glade, G. B., Baker, A. E., Bocian, A., Von Schrader, S., and Starfield, B. (2000). Coordination of specialty referrals and physician satisfaction with referral care. Archives of Pediatrics and Adolescent Medicine 154(5), 499-506.
Gandhi, T. K., Sittig, D. F., Franklin, M., Sussman, A. J., Fairchild, D. G., and Bates, D. W. (2000). Communication breakdown in the outpatient referral process. Journal of General Internal Medicine 15(9), 626-631.
Medicare Payment Advisory Commission (MedPAC) Report to the Congress: Medicare Payment Policy.March, 2006. Retrieved February 22, 2017, from http://medpac.gov/docs/default-source/reports/Mar06_EntireReport.pdf?sfvrsn=0
National Priorities Partnership. National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare. Washington, DC: National Quality Forum; 2008.
Stille, C. J., Jerant, A., Bell, D., Meltzer, D., and Elmore, J. G. (2005). Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice. Annals of Internal Medicine 142(8), 700-708.

Disclaimer

These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

Copyright

Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications. 

CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) is copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation.

Source: https://ecqi.healthit.gov/ecqm/measures/cms50v6