CMS 139 - Falls: Screening for Future Fall Risk

Overview

CMS139v8 (2020)
CMS139v9 (2021)
CMS139v10 (2022)

Identifiers

CMS eCQM IDNQF eCQM IDNQFMIPS Quality ID
CMS139v100101318
*MIE only supports data collection and reporting using eCQM specifications

Definitions

DescriptionPercentage of patients 65 years of age and older who were screened for future fall risk during the measurement period
Initial Patient PopulationPatients aged 65 years and older with a visit during the measurement period
DenominatorEquals Initial Population
Denominator ExclusionsExclude patients who are in hospice care for any part of the measurement period.
NumeratorPatients who were screened for future fall risk at least once within the measurement period
Numerator Exclusions
Denominator Exceptions

Additional Information

Measure TypeProcess measure
Measure ScoringProportion measure
GranularityPatient
Improvement NotationHigher score indicates better quality
DomainPatient Safety

Clinical Instructions

New UI Visit Encounter (valid RC202109+)

Original Visit Encounter

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 LOIN-C 73830-2.
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

NameValue Set
Encounter, Performed: Annual Wellness Visit2.16.840.1.113883.3.526.3.1240
Encounter, Performed: Audiology Visit2.16.840.1.113883.3.464.1003.101.12.1066
Encounter, Performed: Care Services in Long-Term Residential Facility2.16.840.1.113883.3.464.1003.101.12.1014
Encounter, Performed: Discharge Services - Nursing Facility2.16.840.1.113883.3.464.1003.101.12.1013
Encounter, Performed: Home Healthcare Services2.16.840.1.113883.3.464.1003.101.12.1016
Encounter, Performed: Nursing Facility Visit2.16.840.1.113883.3.464.1003.101.12.1012
Encounter, Performed: Office Visit2.16.840.1.113883.3.464.1003.101.12.1001
Encounter, Performed: Online Assessments2.16.840.1.113883.3.464.1003.101.12.1089
Encounter, Performed: Ophthalmological Services2.16.840.1.113883.3.526.3.1285
Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1025
Encounter, Performed: Preventive Care Services-Individual Counseling2.16.840.1.113883.3.464.1003.101.12.1026
Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up2.16.840.1.113883.3.464.1003.101.12.1023
Encounter, Performed: Telephone Visits2.16.840.1.113883.3.464.1003.101.12.1080

Denominator Exclusions

NameValue Set
Encounter, Performed: Encounter Inpatient2.16.840.1.113883.3.666.5.307
Intervention, Order: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15
Intervention, Performed: Hospice care ambulatory2.16.840.1.113762.1.4.1108.15

Numerator

NameValue Set
Assessment, Performed: Falls Screening2.16.840.1.113883.3.464.1003.118.12.1028

Source(s)

eCQI CMS139 Fall Risk Checklist Fall Risk Algorithm


WebChart Documentation

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