Updated January 2019.
- IRIS Registry for EHR: groups and individuals
- EHR through your vendor (if offered): groups and individuals
eMeasure Identifier: CMS139v7
Measure Type: Process - High Priority
NQS Domain: Patient Safety
Meaningful Measure Area: Preventable Healthcare Harm
Instructions: Percentage of patients 65 years of age and older who were screened for future falls risk during the measurement period.
This measure is to be reported a minimum of once per reporting period for patients who were screened for future fall risk at least once within the measurement period.
Future fall risk: Patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury in the past year.
Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.
Initial Patient Population: Patients aged 65 years and older with a visit during the measurement period
Denominator: Equals initial patient population
Denominator exceptions: Documentation of medical reason(s) for not screening for fall risk (eg, patient is not ambulatory)
Denominator exclusions: Exclude patients whose hospice care overlaps the measurement period, and patients who were non-ambulatory at some point in the measurement period.
IRIS Registry EHR Reporting
These are the required elements to be documented at least once a year to meet the measure performance requirements.
- A falls-risk assessment (involving gait/balance assessment as well as vision, and not using a specific survey)
How CMS Scores Your Performance
- If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
- Small practices (≤ 15 clinicians) will receive 3 points,
- Larger practices (> 15 clinicians) will receive 1 point.
- If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
- If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.
||EHR (including EHR–IRIS integration)
||7.24 – 20.26
||20.27 – 36.40
||36.41 – 52.24
||52.25 – 66.72
||65.73 – 78.59
||78.60 – 88.50
||88.51 – 96.55