CMS 139 - Falls: Screening for Future Fall Risk

Overview

CMS139v12 (2024)

CMS139v11 (2023)

CMS139v10 (2022)

Identifiers

CMS eCQM ID NQF eCQM ID NQF MIPS Quality ID
CMS139v12 โ€“ 0101 318

*MIE only supports data collection and reporting using eCQM specifications

Definitions

Description Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
Initial Patient Population Patients aged 65 years and older at the start of the measurement period with a visit during the measurement period
Denominator Equals Initial Population
Denominator Exclusions Exclude patients who are in hospice care for any part of the measurement period.
Numerator Patients who were screened for future fall risk at least once within the measurement period
Numerator Exclusions โ€“
Denominator Exceptions โ€“

Additional Information

Measure Type Process measure
Measure Scoring Proportion measure
Granularity Patient
Improvement Notation Higher score indicates better quality
Domain Patient Safety

Clinical Instructions

Ensure all 65+ year-old patients are screened for future fall risk, at least once within the measurement period. Use the Test and Procedures section of the encounter to order and perform the Fall Risk Screening.

Note
Each system/database will need a Fall Risk Screening order and flowsheet created, in order to result the findings in the Tests and Procedures section of the encounter. The flowsheet must be configured with the Fall Risk Performed LOINC 73830-2.

Numerator Compliance

Preferred Workflow

  1. To document a known test and result or perform the screening in-house while documenting the Visit encounter, open the Tests and Procedures section
  2. Using the autocomplete, begin typing Fall Risk Screening.
  3. Click Add to Exam
  4. Open the newly added test section and record the test results
  5. Complete the test and close the section
  6. Continue documenting the encounter, as appropriate
  7. When completed, Close and Archive the encounter

While documenting the Visit encounter, record the Fall Risk Screening procedure in the Tests and Procedures section of the Visit encounter.

  1. Open the Tests and Procedures section.
  2. Using the autocomplete, begin typing Fall Risk Screening.
  3. Click the Add to Exam button.
  4. After adding the new section, open the Fall Risk Screening and document the findings and complete the questionnaire.
  5. Click the Next button, or close the section.
  6. Continue documenting the encounter, as needed.
  7. When completed, Close and Archive the encounter.

Evidence

Initial Patient Population

Name Value Set
Encounter, Performed: Annual Wellness Visit 2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Audiology Visit 2.16.840.1.113883.3.464.1003.101.12.1066
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: 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: Online Assessments 2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Ophthalmological Services 2.16.840.1.113883.3.526.3.1285
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-Individual Counseling 2.16.840.1.113883.3.464.1003.101.12.1026
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up 2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits 2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

Name Value Set
Encounter, Performed: Encounter Inpatient 2.16.840.1.113883.3.666.5.307
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

Numerator

Name Value Set
Assessment, Performed: Falls Screening 2.16.840.1.113883.3.464.1003.118.12.1028

Source(s)

eCQI CMS139

Fall Risk Checklist

Fall Risk Algorithm


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