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Measure: CMS156

Use of High-Risk Medications in the Elderly

Measure Versions

eMeasure Code Measure Year Full Version Number Title
CMS156v10 2022 10.2.000 Use of High-Risk Medications in Older Adults
CMS156v9 2021 9.3.000 Use of High-Risk Medications in Older Adults
CMS156v8 2020 8.3.000 Use of High-Risk Medications in the Elderly
CMS156v7 2019 7.3.000 Use of High-Risk Medications in the Elderly
CMS156v6 2018 6.4.000 Use of High-Risk Medications in the Elderly
CMS156v5 2017 5.1.000 Use of High-Risk Medications in the Elderly


Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two of the same high-risk medications.


The intent of Numerator 1 of the measure is to assess if the patient has been prescribed at least one high-risk medication. The intent of Numerator 2 of the measure is to assess if the patient has been prescribed at least two of the same high-risk medications. The intent of the measure is to assess if the reporting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the reporting provider also ordered a high-risk medication for them. CUMULATIVE MEDICATION DURATION is an individual's total number of medication days over a specific period; the period counts multiple prescriptions with gaps in between, but does not count the gaps during which a medication was not dispensed. To determine the cumulative medication duration, determine first the number of the Medication Days for each prescription in the period: the number of doses divided by the dose frequency per day. Then add the Medication Days for each prescription without counting any days between the prescriptions. For example, there is an original prescription for 30 days with 2 refills for thirty days each. After a gap of 3 months, the medication was prescribed again for 60 days with 1 refill for 60 days. The cumulative medication duration is (30 x 3) + (60 x 2) = 210 days over the 10 month period.

Patient Group Definitions

Group Description Instructions Links
Initial PopulationPatients 65 years and older who had a visit during the measurement periodWebchart Instructions
DenominatorEquals Initial PopulationWebchart Instructions
Denominator ExclusionsExclude patients whose hospice care overlaps the measurement periodWebchart Instructions
NumeratorNumerator 1: Patients with an order for at least one high-risk medication during the measurement period Numerator 2: Patients with at least two orders for the same high-risk medication during the measurement periodWebchart Instructions
Numerator ExclusionsNot ApplicableWebchart Instructions
Denominator ExceptionsNone


Full eMeasure Code eMeasure Identifier Measure Year Version NQF # GUID
CMS156v7 156 2019 7.3.000 0022 A3837FF8-1ABC-4BA9-800E-FD4E7953ADBD
Steward Developer Endorsed By
National Committee for Quality Assurance National Committee for Quality Assurance National Quality Forum
Scoring Method Measure Type Stratification Risk Adjustment
Proportion PROCESS None None

Rate Aggregation


Improvement Notation

Lower score indicates better quality


Older adults receiving inappropriate medications are more likely to report poorer health status at follow-up, compared to those who receive appropriate medications (Fu, Liu, and Christensen 2004). A study of the prevalence of potentially inappropriate medication use in older adults found that 40 percent of individuals 65 and older filled at least one prescription for a potentially inappropriate medication and 13 percent filled two or more (Fick et al. 2008). While some adverse drug events are not preventable, studies estimate that between 30 and 80 percent of adverse drug events in the elderly are preventable (MacKinnon and Hepler 2003). Reducing the number of inappropriate prescriptions can lead to improved patient safety and significant cost savings. Conservative estimates of extra costs due to potentially inappropriate medications in the elderly average $7.2 billion a year (Fu et al. 2007). Medication use by older adults will likely increase further as the U.S. population ages, new drugs are developed, and new therapeutic and preventive uses for medications are discovered (Rothberg et al. 2008). The annual direct costs of preventable adverse drug events (ADEs) in the Medicare population have been estimated to exceed $800 million (IOM, 2007). By the year 2030, nearly one in five U.S. residents is expected to be aged 65 years or older; this age group is projected to more than double in number from 38.7 million in 2008 to more than 88.5 million in 2050. Likewise, the population aged 85 years or older is expected to increase almost four-fold, from 5.4 million to 19 million between 2008 and 2050. As the elderly population continues to grow, the number of older adults who present with multiple medical conditions for which several medications are prescribed continues to increase, resulting in polypharmacy (Gray and Gardner 2009).

Clinical Recommendation Statement

The measure is based on recommendations from the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. The criteria were developed through key clinical expert consensus processes by Beers in 1997, Zahn in 2001 and an updated process by Fick in 2003, 2012 and 2015. The Beers Criteria identifies lists of drugs that are potentially inappropriate for all older adults and drugs that are potentially inappropriate in the elderly based on various high-risk factors such as dosage, days supply and underlying diseases or conditions. NCQA's Medication Management expert panel selected a subset of drugs that should be used with caution in the elderly for inclusion in the proposed measure based upon the recommendations in the Beers Criteria.  

Certain medications (MacKinnon 2003) are associated with increased risk of harm from drug side-effects and drug toxicity and pose a concern for patient safety. There is clinical consensus that these drugs pose increased risks in the elderly (Kaufman 2005). Studies link prescription drug use by the elderly with adverse drug events that contribute to hospitalization, increased length of hospital stay, increased duration of illness, nursing home placement and falls and fractures that are further associated with physical, functional and social decline in the elderly (AHRQ 2009).


A high-risk medication is identified by either of the following: a. A prescription for medications classified as high risk at any dose and for any duration b. Prescriptions for medications classified as high risk at any dose with greater than a 90 day supply

Transmission Format


Applicable Value Sets

Category Value Set OID
Encounter, Performed Annual Wellness Visit 2.16.840.1.113883.3.526.3.1240
Encounter, Performed Care Services in Long-Term Residential Facility 2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed Discharge Services - Nursing Facility 2.16.840.1.113883.3.464.1003.101.12.1013
Encounter, Performed Encounter Inpatient 2.16.840.1.113883.3.666.5.307
Encounter, Performed Home Healthcare Services 2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed Nursing Facility Visit 2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed Office Visit 2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed Ophthalmologic Outpatient Visit 2.16.840.1.113883.3.464.1003.101.11.1206
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
Intervention, Order Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Intervention, Performed Hospice care ambulatory 2.16.840.1.113762.1.4.1108.15
Medication, Order Acetaminophen / Butalbital 2.16.840.1.113883.3.464.1003.196.12.1317
Medication, Order Acetaminophen / Butalbital / Caffeine 2.16.840.1.113883.3.464.1003.196.12.1363
Medication, Order Acetaminophen / Butalbital / Caffeine / Codeine 2.16.840.1.113883.3.464.1003.196.12.1326
Medication, Order Acetaminophen / Chlorpheniramine / Dextromethorphan 2.16.840.1.113883.3.464.1003.196.12.1421
Medication, Order Acetaminophen / Chlorpheniramine / Dextromethorphan / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1310
Medication, Order Acetaminophen / Chlorpheniramine / Dextromethorphan / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1321
Medication, Order Acetaminophen / Chlorpheniramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1328
Medication, Order Acetaminophen / Chlorpheniramine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1316
Medication, Order Acetaminophen / Dexbrompheniramine 2.16.840.1.113883.3.464.1003.196.12.1405
Medication, Order Acetaminophen / Dextromethorphan / Diphenhydramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1399
Medication, Order Acetaminophen / Dextromethorphan / Doxylamine 2.16.840.1.113883.3.464.1003.196.12.1338
Medication, Order Acetaminophen / Dextromethorphan / Doxylamine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1287
Medication, Order Acetaminophen / Diphenhydramine 2.16.840.1.113883.3.464.1003.196.12.1350
Medication, Order Acetaminophen / Diphenhydramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1318
Medication, Order Amitriptyline / Chlordiazepoxide 2.16.840.1.113883.3.464.1003.196.12.1286
Medication, Order Amitriptyline / Perphenazine 2.16.840.1.113883.3.464.1003.196.12.1428
Medication, Order Amitriptyline Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1373
Medication, Order Amoxapine 2.16.840.1.113883.3.464.1003.196.12.1273
Medication, Order Anti Infectives, other 2.16.840.1.113883.3.464.1003.196.12.1481
Medication, Order Aspirin / Butalbital / Caffeine 2.16.840.1.113883.3.464.1003.196.12.1347
Medication, Order Atropine / Diphenoxylate 2.16.840.1.113883.3.464.1003.196.12.1274
Medication, Order Atropine / Hyoscyamine / Phenobarbital / Scopolamine 2.16.840.1.113883.3.464.1003.196.12.1355
Medication, Order Benztropine 2.16.840.1.113883.3.464.1003.196.12.1361
Medication, Order Brompheniramine 2.16.840.1.113883.3.464.1003.196.12.1427
Medication, Order Brompheniramine / Codeine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1409
Medication, Order Brompheniramine / Codeine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1450
Medication, Order Brompheniramine / Dextromethorphan / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1325
Medication, Order Brompheniramine / Dextromethorphan / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1339
Medication, Order Brompheniramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1327
Medication, Order Brompheniramine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1332
Medication, Order Butabarbital 2.16.840.1.113883.3.464.1003.196.12.1402
Medication, Order Carbinoxamine 2.16.840.1.113883.3.464.1003.196.12.1306
Medication, Order Carisoprodol 2.16.840.1.113883.3.464.1003.196.12.1369
Medication, Order Chlophedianol / Chlorpheniramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1412
Medication, Order Chlophedianol / Dexchlorpheniramine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1447
Medication, Order Chlorpheniramine 2.16.840.1.113883.3.464.1003.196.12.1352
Medication, Order Chlorpheniramine / Codeine 2.16.840.1.113883.3.464.1003.196.12.1301
Medication, Order Chlorpheniramine / Dextromethorphan / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1312
Medication, Order Chlorpheniramine / Dextromethorphan / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1337
Medication, Order Chlorpheniramine / Hydrocodone 2.16.840.1.113883.3.464.1003.196.12.1330
Medication, Order Chlorpheniramine / Hydrocodone / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1299
Medication, Order Chlorpheniramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1343
Medication, Order Chlorpheniramine / Phenylephrine / Phenyltoloxamine 2.16.840.1.113883.3.464.1003.196.12.1453
Medication, Order Chlorpheniramine / Phenylephrine / Pyrilamine 2.16.840.1.113883.3.464.1003.196.12.1309
Medication, Order Chlorpheniramine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1315
Medication, Order Chlorpropamide 2.16.840.1.113883.3.464.1003.196.12.1303
Medication, Order Chlorzoxazone 2.16.840.1.113883.3.464.1003.196.12.1362
Medication, Order Clemastine 2.16.840.1.113883.3.464.1003.196.12.1308
Medication, Order Clomipramine 2.16.840.1.113883.3.464.1003.196.12.1336
Medication, Order Conjugated Estrogens 2.16.840.1.113883.3.464.1003.196.12.1357
Medication, Order Conjugated Estrogens / Medroxyprogesterone 2.16.840.1.113883.3.464.1003.196.12.1324
Medication, Order Cyclobenzaprine Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1372
Medication, Order Cyproheptadine 2.16.840.1.113883.3.464.1003.196.12.1277
Medication, Order Desiccated Thyroid 2.16.840.1.113883.3.464.1003.196.12.1354
Medication, Order Desipramine 2.16.840.1.113883.3.464.1003.196.12.1278
Medication, Order Dexbrompheniramine 2.16.840.1.113883.3.464.1003.196.12.1375
Medication, Order Dexbrompheniramine / Dextromethorphan / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1426
Medication, Order Dexbrompheniramine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1430
Medication, Order Dexbrompheniramine Maleate / Pseudoephedrine Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1429
Medication, Order Dexchlorpheniramine 2.16.840.1.113883.3.464.1003.196.12.1300
Medication, Order Dexchlorpheniramine / Pseudoephedrine 2.16.840.1.113883.3.464.1003.196.12.1425
Medication, Order Dextromethorphan / Diphenhydramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1397
Medication, Order Dextromethorphan / Doxylamine 2.16.840.1.113883.3.464.1003.196.12.1452
Medication, Order Dicyclomine 2.16.840.1.113883.3.464.1003.196.12.1279
Medication, Order Dienogest / Estradiol Multiphasic 2.16.840.1.113883.3.464.1003.196.12.1398
Medication, Order Dimenhydrinate 2.16.840.1.113883.3.464.1003.196.12.1500
Medication, Order Diphenhydramine 2.16.840.1.113883.3.464.1003.196.12.1293
Medication, Order Diphenhydramine / Phenylephrine 2.16.840.1.113883.3.464.1003.196.12.1307
Medication, Order Diphenhydramine Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1371
Medication, Order Dipyridamole 2.16.840.1.113883.3.464.1003.196.12.1349
Medication, Order Disopyramide 2.16.840.1.113883.3.464.1003.196.12.1311
Medication, Order Drospirenone / Estradiol 2.16.840.1.113883.3.464.1003.196.12.1410
Medication, Order Esterified Estrogens 2.16.840.1.113883.3.464.1003.196.12.1419
Medication, Order Esterified Estrogens / Methyltestosterone 2.16.840.1.113883.3.464.1003.196.12.1320
Medication, Order Estradiol 2.16.840.1.113883.3.464.1003.196.12.1365
Medication, Order Estradiol / Norethindrone 2.16.840.1.113883.3.464.1003.196.12.1323
Medication, Order Estropipate 2.16.840.1.113883.3.464.1003.196.12.1319
Medication, Order Glyburide 2.16.840.1.113883.3.464.1003.196.12.1368
Medication, Order Glyburide / Metformin 2.16.840.1.113883.3.464.1003.196.12.1360
Medication, Order Guanfacine 2.16.840.1.113883.3.464.1003.196.12.1341
Medication, Order High Risk Medications for the Elderly 2.16.840.1.113883.3.464.1003.196.12.1253
Medication, Order High-Risk Medications With Days Supply Criteria 2.16.840.1.113883.3.464.1003.196.12.1254
Medication, Order Hydrochlorothiazide / Methyldopa 2.16.840.1.113883.3.464.1003.196.12.1414
Medication, Order Hydroxyzine 2.16.840.1.113883.3.464.1003.196.12.1374
Medication, Order Hyoscyamine 2.16.840.1.113883.3.464.1003.196.12.1501
Medication, Order Hyoscyamine / Methenamine / Mblue / Phenyl Salicyl 2.16.840.1.113883.3.464.1003.196.12.1503
Medication, Order Hyoscyamine / Methenamine / Mblue / Phenyl Salicyl / Sodium Biphosphate 2.16.840.1.113883.3.464.1003.196.12.1504
Medication, Order Hyoscyamine / Methenamine / Mblue / Sodium Biphosphate 2.16.840.1.113883.3.464.1003.196.12.1505
Medication, Order Imipramine 2.16.840.1.113883.3.464.1003.196.12.1359
Medication, Order Indomethacin 2.16.840.1.113883.3.464.1003.196.12.1366
Medication, Order Isoxsuprine 2.16.840.1.113883.3.464.1003.196.12.1422
Medication, Order Ketorolac Tromethamine 2.16.840.1.113883.3.464.1003.196.12.1364
Medication, Order List of Single RxNorm Code Concepts for High Risk Drugs for the Elderly 2.16.840.1.113883.3.464.1003.196.12.1272
Medication, Order Meclizine 2.16.840.1.113883.3.464.1003.196.12.1506
Medication, Order Megestrol 2.16.840.1.113883.3.464.1003.196.12.1342
Medication, Order Meperidine 2.16.840.1.113883.3.464.1003.196.12.1351
Medication, Order Meprobamate 2.16.840.1.113883.3.464.1003.196.12.1284
Medication, Order Metaxalone 2.16.840.1.113883.3.464.1003.196.12.1358
Medication, Order Methocarbamol 2.16.840.1.113883.3.464.1003.196.12.1370
Medication, Order Methyldopa 2.16.840.1.113883.3.464.1003.196.12.1331
Medication, Order Nifedipine 2.16.840.1.113883.3.464.1003.196.12.1353
Medication, Order Nonbenzodiazepine hypnotics 2.16.840.1.113883.3.464.1003.196.12.1480
Medication, Order Nortriptyline 2.16.840.1.113883.3.464.1003.196.12.1507
Medication, Order Orphenadrine 2.16.840.1.113883.3.464.1003.196.12.1302
Medication, Order Paroxetine 2.16.840.1.113883.3.464.1003.196.12.1508
Medication, Order Phenobarbital 2.16.840.1.113883.3.464.1003.196.12.1348
Medication, Order Promethazine Hydrochloride 2.16.840.1.113883.3.464.1003.196.12.1367
Medication, Order Protriptyline 2.16.840.1.113883.3.464.1003.196.12.1509
Medication, Order Pseudoephedrine / Triprolidine 2.16.840.1.113883.3.464.1003.196.12.1345
Medication, Order Trihexyphenidyl 2.16.840.1.113883.3.464.1003.196.12.1334
Medication, Order Trimipramine 2.16.840.1.113883.3.464.1003.196.12.1285
Medication, Order Triprolidine 2.16.840.1.113883.3.464.1003.196.12.1408
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


Campanelli, Christine M. 2012. "American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults: the American Geriatrics Society 2012 Beers Criteria Update Expert Panel." Journal of the American Geriatrics Society 60(4): 616.
American Geriatrics Society 2015 Beers Criteria Update Expert Panel. 2015. "American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults." Journal of the American Geriatrics Society. 63(11): 2227-2246.
Zhan, C, et al. Potentially inappropriate medication use in the community-dwelling elderly. JAMA 2001; 286(22):2823-2868.
Beers, M.H. Explicit criteria for determining potentially inappropriate medication use by the elderly. Arch Intern Med 1997; 157:1531-1536.
Fick, DM, et al. Updating the Beers criteria for potentially inappropriate medication use in older adults. Arch Intern Med 2003; 163:2716-2724.
Fu, A.Z., G.G. Liu, D.B. Christensen. 2004. "Inappropriate Medication Use and Health Outcomes in the Elderly." Journal of the American Geriatrics Society 52(11): 1934-1939.
Gray, C.L, and C. Gardner. 2009. "Adverse Drug Events in the Elderly: An Ongoing Problem." J Manag Care Pharm 15(7):568-71.
Fick, D.M., L.C. Mion, M.H. Beers, J.L. Waller. 2008. "Health Outcomes Associated with Potentially Inappropriate Medication Use in Older Adults." Research in Nursing & Health. 31(1): 42-51.
AHRQ, "Use of High-Risk Medications in the Elderly: Percentage of Medicare Members 65 years of Age and Older who Received at least two different High-Risk Medications." National Quality Measures Clearinghouse. (Accessed Web page: December 14, 2015).
Institute of Medicine (IOM). 2007. Preventing Medication Errors/Committee on Identifying and Preventing Medication Errors. Ed. Aspden P., J.A. Wolcott, J.L. Bootman, L.R. Cronenwatt LR. Quality Chasm Series. Washington, DC: National Academy Press.
MacKinnon, N.J. and C.D. Hepler. 2003. "Indicators of Preventable Drug-related Morbidity in Older Adults: Use Within a Managed Care Organization." J Managed Care Pharm 9:134-41.
Kaufman MB, et al. Effect of Prescriber Education on the Use of Medications Contraindicated in Older Adults in a Managed Medicare Population. J Manag Care Pharm 2005 April/May; 11(3):211-219.
Rothberg, M.B., P.S. Perkow, F. Liu, B. Korc-Grodzicki, M.J. Brennan, S. Bellantonio, M. Heelon, P.K. Lindenauer. 2008. "Potentially Inappropriate Medication Use in Hospitalized Elders." J Hosp Med 3:91-102.


The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE 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].


This Physician Performance Measure (Measure) and related data specifications are owned and stewarded by the Centers for Medicare & Medicaid Services (CMS). CMS contracted (Contract HHSM-500-2011-00079C) with the National Committee for Quality Assurance (NCQA) to develop this electronic measure. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

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 third party codes contained in the specifications.

CPT(R) contained in the Measure specifications is copyright 2004-2017 American Medical Association. LOINC(R) copyright 2004-2017 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2017 International Health Terminology Standards Development Organisation. ICD-10 copyright 2017 World Health Organization. All Rights Reserved.