American academy of neurology
Appendix e-3: AAN Parkinson's Disease Measurement Set
Parkinson's Disease
Physician Performance Measurement Set
As of December 16, 2009
2009 American Academy of Neurology. All rights reserved. AAN BOD approved 12.21.09.
Appendix e-3: AAN Parkinson's Disease Measurement Set
Physician Performance Measures (measures) and related data specifications developed by the American Academy of
Neurology (AAN) are intended to facilitate quality improvement activities by physicians.
These measures are intended to assist physicians in enhancing quality of care. Measures are designed for use by any physician
who manages the care of a patient for a specific condition or for prevention. These measures are not clinical guidelines and do
not establish a standard of medical care, and have not been tested for all potential applications.
Measures are subject to review and may be revised or rescinded at any time by the AAN. The measures may not be altered without prior written approval from the AAN. The measures, while copyrighted, can be reproduced and distributed, without
modification, for noncommercial purposes (e.g. use by health care providers in connection with their practices). Commercial
use is defined as the sale, license, or distribution of the measures for commercial gain, or incorporation of the measures into a
product or service that is sold, licensed, or distributed for commercial gain. Commercial uses of the measures require a license
agreement between the user and the AAN. Neither the AAN nor its members shall be responsible for any use of the
THESE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. 2009 American Academy of Neurology. All rights reserved.
Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary coding sets
should obtain all necessary licenses from the owners of these code sets. The AAN and its members disclaim all liability for use
or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.
CPT ® is a registered trademark of the American Medical Association.
2009 American Academy of Neurology. All rights reserved. AAN BOD approved 12.21.09.
Appendix e-3: AAN Parkinson's Disease Measurement Set
American Academy of Neurology
Parkinson's Disease
Physician Performance Measurement Set
William Weiner, MD, FAAN (University of Maryland, Co-Chair)
Stewart Factor, DO, FAAN (Emory University, Co-Chair)
Paul Moberg, PhD, ABPP/CN (Pennsylvania,
Expert Panel Facilitators
Workgroup Member)
Christopher Bever Jr., MD, MBA, FAAN (VA
Maryland Healthcare System)
American Psychiatric Association
Eric M. Cheng, MD, MS (VA Greater Los Angeles)
Laura Marsh, MD (Texas, Workgroup Member)
Patient Organization Representatives
Movement Disorder Society
Daniel Tarsy, MD, FAAN (Massachusetts,
American Parkinson's Disease Association
Workgroup Member)
Michele Popadynec, RN (New York, Workgroup
National Academy of Neuropsychology
Alexander Tröster, PhD (North Carolina, Workgroup
National Parkinson Foundation
Joyce Oberdorf, MA (Florida, Workgroup Member)
Coding Specialists
Parkinson's Disease Foundation
Marc Nuwer, MD, PhD, FAAN (California, Coding
Jim Beck, PhD (New York, Workgroup Member)
Specialist)
Mustafa Saad Siddiqui, MD (North Carolina, Coding
Physician Association Representatives
Specialist)
American Academy of Family Physicians
Insurance Representatives
H. James Brownlee Jr., MD (Florida, Workgroup
Robert M. Kropp, MD, MBA (Florida, Aetna
American Academy of Neurology
Insurance Representative)
Lisa Shulman, MD, FAAN (Maryland, Workgroup
Anthem Blue Cross and Blue Shield
Sotirios A. Parashos, MD, PhD (Minnesota,
Wesley B. Wong MD, MMM (Indiana, Anthem Blue
Workgroup Member)
Cross and Blue Shield Insurance Representative)
Helen Bronte-Stewart, MD, FAAN (California,
Workgroup Member)
Humana, Inc
.
Janis Miyasaki, MD, FAAN (Ontario, Workgroup
Monte Masten, MD (Illinois, Humana Insurance
Marian Evatt, MD (Georgia, Workgroup Member)
UnitedHealth Group, Inc.
American Association of Neurosurgeons /Congress of
David Stumpf, MD (Illinois, UnitedHealth Group
Neurological Surgeons
Insurance Representataive)
Karl Sillay, MD (Wisconsin, Workgroup Member)
American Neurological Association
Rebecca Kresowik (Methodologist)
Blair Ford, MD, FAAN (New York, Workgroup
American Academy of Neurology Staff
Rebecca Swain-Eng, MS (Minnesota, AAN Staff)
American Psychological Association
Sarah Tonn, MPH (Minnesota, AAN Staff)
2009 American Academy of Neurology. All rights reserved. AAN BOD approved 12.21.09.
AAN Parkinson's Disease Physician Performance Measurement Set
Purpose of Measures
These clinical performance measures, which the American Academy of Neurology (AAN) developed using
the model for performance measure development from the Physician Consortium for Performance
Improvement (PCPI), are designed for use in individual quality improvement. The measures may also be used in data registries, continuing medical education (CME) programs, and board certification programs. Unless
otherwise indicated, the measures are also appropriate for accountability if the necessary methodological,
statistical, and implementation rules are met.
The measure titles listed below may be used for accountability:
Measure 1: Annual Parkinson's Disease Diagnosis Review
Measure 2: Psychiatric Disorders or Disturbances Assessment
Measure 3: Cognitive Impairment or Dysfunction Assessment
Measure 4: Querying about Symptoms of Autonomic Dysfunction
Measure 5: Querying about Sleep Disturbances
Measure 6: Querying about Falls
Measure 7: Parkinson's Disease Rehabilitative Therapy Options
Measure 8: Parkinson's Disease Related Safety Issues Counseling
Measure 9: Querying about Medication-related Motor Complications
Measure 10: Parkinson's Disease Medical and Surgical Treatment Options Reviewed
Intended Audience, Care Setting, and Patient Population
These measures are designed for use by physicians and other eligible health professionals who provide care to
individuals diagnosed with Parkinson's disease. The measures may be used in the emergency department only if the physician or eligible provider uses the appropriate International Classification of Disease (ICD)-9 and
Current Procedural Terminology (CPT®) codes as described under each individual measure. The measures
are intended to be used to calculate performance and/or to report measurement at the individual physician
Measure Specifications
The AAN seeks to specify measures for implementation using multiple data sources, including paper medical
records, administrative (claims) data, and, in particular, Electronic Health Record Systems (EHRS). Specifications for reporting on the measures for Parkinson's disease using administrative (claims) data are
included in this document. The AAN has identified codes for these measures, including ICD-9 and CPT
(Evaluation and Management Codes, Category I and, where applicable, Category II codes). Specifications for
additional data sources, including EHRS, will be fully developed at a later date.
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Measure Exclusions
The AAN used the PCPI policy "Specification and categorization of measure exclusions: recommendations
to PCPI work groups" as the basis for defining exclusions. (Available at: http://www.ama-
assn.org/ama1/pub/upload/mm/370/exclusions053008.pdf. Accessed September 2008-December 2009)
This methodology is described below.
For process measures, the PCPI provides three categories of reasons for which a patient may be excluded
from the denominator of an individual measure:
Medical Reasons
- Not indicated (absence of organ/limb, already received/performed, other) - Contraindicated (patient allergy history, potential adverse drug interaction, other)
Patient Reasons
- Patient declined - Social or religious reasons - Other patient reasons
System Reasons
- Resources to perform the services not available - Insurance coverage/Payer-related limitations - Other reasons attributable to health care delivery system
These measure exclusion categories are not available uniformly across all measures; for each measure, there
must be a clear rationale to permit an exclusion for a medical, patient, or system reason. The exclusion of a
patient may be reported by appending the appropriate modifier to the CPT Category II code designated for
Medical reasons: modifier 1P
Patient reasons: modifier 2P
System reasons: modifier 3P
Although this methodology does not require the external reporting of more detailed exclusion data, the PCPI
recommends that physicians document the
specific reasons for exclusion in patients' medical records, for
purposes of optimal patient management and audit-readiness. The PCPI also advocates for the systematic
review and analysis of each physician's exclusions data to identify practice patterns and opportunities for
quality improvement. For example, it is possible for implementers to calculate the percentage of patients
whom physicians have identified as meeting the criteria for exclusion.
Please refer to the documentation for each individual measure for information on acceptable exclusion categories and the codes and modifiers to be used for reporting.
Data Capture and Measure Calculation
The intent of this measurement set is to encourage physicians to collect data on each patient eligible for a
measure. Physicians should receive feedback on measures both at the patient level to facilitate patient
management and in the aggregate to identify opportunities for improvement across a physician's patient
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Measure calculations will differ depending on whether a rate is being calculated for performance or reporting
The method of calculation for performance follows three steps. First, identify the patients who meet the eligibility criteria for the denominator (PD); second, identify which of those patients meet the numerator
criteria (A); and third, for those patients who do not meet the numerator criteria, determine whether an
appropriate exclusion applies and then subtract those patients from the denominator (C) (see examples
The methodology also enables implementers to calculate the rates of exclusions and to analyze further both
low rates and high rates, as appropriate (see examples below).
The method of calculation for reporting differs. One program that currently focuses on reporting rates is the
Centers for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI). Under
that program's current design, there is a reporting denominator determined solely from claims data (CPT and
ICD-9), which in some cases results in a reporting denominator that is much larger than the eligible
population for the performance denominator. Additional components of the reporting denominator are
explained below.
The components that make up the numerator for reporting include all patients from the eligible population for which the physician has reported, including the number of patients who meet the numerator criteria (A),
the number of patients for whom valid exclusions apply (C), and the number of patients who do not meet the
numerator criteria (D). These components, where applicable, are summed to make up the inclusive reporting
numerator. The calculation for reporting will be the reporting numerator divided by the reporting
denominator (see examples below).
Examples of calculations for reporting and performance are provided for each measure.
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Numerator (A) includes: Number of patients meeting numerator criteria
Performance Denominator (PD) includes: Number of patients meeting criteria for denominator
Denominator Exclusion (C) includes: Number of patients with valid medical, patient, or system
exclusions (where applicable; will differ by measure)
Performance Calculation
A (# of patients meeting numerator criteria
PD (# of patients in denominator) - C (# of patients with valid denominator exclusions)
It is also possible to calculate the percentage of patients either excluded overall or excluded by medical,
patient, or system reason where applicable:
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Overall Exclusion Calculation
C (# of patients with any valid exclusion)
PD (# of patients in denominator)
Exclusion Calculation by Type
C (# patients with
C (# patients with
C (# patients with
PD (# patients in
PD (# patients in
PD (# patients in
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with two components: Reporting
Numerator and Reporting Denominator.
Reporting Numerator includes each of the following components, where applicable (there
may be instances where there are no patients to include in A, C, D, or E):
A. Number of patients meeting additional denominator criteria (for measures where true
denominator cannot be determined through ICD-9 and CPT Category I coding alone) AND
numerator criteria
C. Number of patients with valid medical, patient, or system exclusions (where applicable; will differ
D. Number of patients not meeting numerator criteria and without a valid exclusion
E. All other patients not meeting additional denominator criteria (for measures where true
denominator cannot be determined through ICD-9 and CPT Category I coding alone)
Reporting Denominator (RD) includes:
RD. Denominator criteria (identifiable through ICD-9 and CPT Category I coding)
Reporting Calculation
A (# of patients meeting additional denominator criteria AND numerator criteria) +
C (# of
patients with valid exclusions) +
D (# of patients NOT meeting numerator criteria) +
E (# of
patients not meeting additional denominator criteria)
RD (# of patients in denominator)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure #1: Annual Parkinson's Disease Diagnosis Review
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients who had their Parkinson's disease diagnosis reviewed, including a review of current
medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the
presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to
levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or
dysautonomia) at least annually.
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
No exclusions appropriate for this measure.
Measure: All patients with a diagnosis of Parkinson's disease who had their Parkinson's disease diagnosis
reviewed, including a review of current medications and a review for the presence of atypical features (e.g.,
falls at presentation and early in the disease course, poor response to levodopa, symmetry at onset, rapid
progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
The diagnosis of PD should be reviewed regularly (6-12 month intervals seen to review diagnosis) and re-
considered if atypical clinical features develop. (Level D (DS)) NICE GL35 (June 2006)
Determining the presence of the following clinical features in early stages of disease should be considered to distinguish PD from other parkinsonian syndromes: 1) falls at presentation and early in the disease course, 2)
poor response to levodopa, 3) symmetry at onset, 4) rapid progression (to Hoehn and Yahr stage 3 in 3 years),
5) lack of tremor, and 6) dysautonomia (urinary urgency/incontinence and fecal incontinence, urinary
retention requiring catheterization, persistent erectile failure, or symptomatic orthostatic hypotension) (Level
B) AAN QSS PD (April 2006)
All veterans with the suspected diagnosis of PD who are also receiving medications known to cause
parkinsonism (e.g. neuroleptics) should have a trial of withdrawal of these medications, a trial of low-potency neuroleptic, or documentation in the medical record that the medication could not be withdrawn before
making the diagnosis of PD. Cheng #1 (Assessment of medication-induced PD) 2004
AAN QSS PD Diag. (April 2006) Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth G, Weiner
WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: diagnosis
and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11; 66(7):968-75.
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary
Care (2006) London: Royal College of Physicians
Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara.
Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004 (P136-150)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Rationale for the Measure:
Because the diagnosis of Parkinson's disease is clinical with no confirmatory laboratory or imaging study, it is
important to review the diagnosis periodically in order to ensure that no atypical features emerge. The emergence of atypical features in a patient previously thought to have Parkinson's disease will influence
prognosis and medical treatment. It has been demonstrated that in the course of caring for patients with
suspected Parkinson's disease, 10-15% will ultimately have a different pathologic diagnosis. This measure will
alert the clinician to the emergence of atypical features in Parkinson's disease and suggest alternate diagnostic
Hughes AJ, Daniel SE, Kilford L, Lees AJ. Accuracy of clinical diagnosis of idiopathic Parkinson's disease: a
clinico-pathological study of 100 cases. J Neurol Neurosurg Psychiatry. 1992 Mar; 55(3):181-4.
Hughes AJ, Ben-Shlomo Y, Daniel SE, Lees AJ. What features improve the accuracy of clinical diagnosis in
Parkinson's disease: a clinicopathologic study. Neurology. 1992 Jun;42(6):1142-6.
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator and Denominator.
Performance Numerator (A) includes:
Patients who had their Parkinson's disease diagnosis reviewed, including a review of current medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the presence of atypical
features (e.g., falls at presentation and early in the disease course, poor response to levodopa, symmetry at
onset, rapid progression [ to Hoehn and Yahr stage 3 in 3 years], lack of tremor or dysautonomia) at least
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Performance Calculation
A (# of patients meeting measure criteria)
PD (# of patients in denominator)
Components for this measure are defined as:
# of patients who had their Parkinson's disease diagnosis reviewed, including a
review of current medications (e.g., medications that can produce Parkinson-like
signs or symptoms) and a review for the presence of atypical features (e.g., falls at
presentation and early in the disease course, poor response to levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack
of tremor or dysautonomia) at least annually
# of patients with a diagnosis of Parkinson's disease
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients with documentation of Parkinson's disease diagnosis reviewed, including a review of current
medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the
presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to
levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or
dysautonomia). at least annually
D. Patients with no documentation of Parkinson's disease diagnosis reviewed, including a review of current
medications (e.g., medications that can produce Parkinson-like signs or symptoms) and a review for the presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to
levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or
dysautonomia) at least annually.
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meetin g numerator criteria)
+ D (# of patients NOT me eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients who had their Parkinson's disease diagnosis reviewed, including a
review of current medications (e.g., medications that can produce Parkinson-like
signs or symptoms) and a review for the presence of atypical features (e.g., falls at
presentation and early in the disease course, poor response to levodopa,
symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack
of tremor or dysautonomia) at least annually
# of patients with no documentation of Parkinson's disease diagnosis reviewed,
including a review of current medications (e.g., medications that can produce
Parkinson-like signs or symptoms) and a review for the presence of atypical
features (e.g., falls at presentation and early in the disease course, poor response
to levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in
3 years], lack of tremor or dysautonomia) at least annually
# of patients with a diagnosis of Parkinson's disease
Measure Specifications- Annual Parkinson's Disease Diagnosis Review
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patients who had their Parkinson's disease diagnosis reviewed, including a review of current
medications (e.g., medications than can produce Parkinson-like signs or symptoms) and a review for the presence of atypical features (e.g., falls at presentation and early in the disease course, poor response to
levodopa, symmetry at onset, rapid progression [to Hoehn and Yahr stage 3 in 3 years], lack of tremor or
dysautonomia) at least annually.
Report the CPT Category II,
Annual Parkinson's Disease Diagnosis Review 1400F
Denominator Exclusion(s): None.
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure #2: Psychiatric Disorders or Disturbances Assessment
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients who were assessed for psychiatric disorders or disturbances (e.g., psychosis, depression,
anxiety disorder, apathy, or impulse control disorder) at least annually.
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
No exclusions appropriate for this measure.
Measure: All patients with a diagnosis of Parkinson's disease who were assessed for psychiatric disorders or
disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
Clinicians should be aware of dopamine dysregulation syndrome, an uncommon disorder in which
dopaminergic medication misuse is associated with abnormal behaviors, including hypersexuality, pathological
gambling and stereotypic motor acts. This syndrome may be difficult to manage. (Level D) NICE GL35 (Jun 2006)
If a veteran with PD presents with new onset of one of the following symptoms: sad mood, feeling down;
insomnia or difficulties with sleep; apathy or loss of interest in pleasurable activities; complains of memory
loss; unexplained weight loss of greater than 5% in the past month or 10% over one year; or unexplained
fatigue or low energy, then the patient should be asked about or treated for depression, or referred to a mental
health professional within two weeks of presentation. (Outcomes Impact 5; Room for Improvement 4;
Overall utility rating 4) Cheng 2004 Clinicians should have a low threshold for diagnosing depression in PD. (Level D) NICE GL35 (Jun 2006)
All veterans with PD should be reassessed for complications of PD (including, but not limited to functional
status, excessive daytime somnolence, speech and swallowing difficulties, dementia, depression, and psychosis)
at least on an annual basis. Cheng #10 (Reassessment for complications for PD) 2004
All people with PD and psychosis should receive a general medical evaluation and treatment for any precipitating condition. (Level D) NICE GL35 (Jun 2006)
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary
Care (2006) London: Royal College of Physicians
Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara.
Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Rationale for the Measure:
Parkinson's disease is associated with a wide range of psychiatric disorders. Some of these problems are
related to the disease itself and some are related to the medications used to treat the disease. These disorders range from anxiety and depression to psychosis and impulse control disorder. It has been demonstrated that
depression, in particular, has been often overlooked as a diagnostic possibility in patients with Parkinson's
disease. In fact, it has been demonstrated that depression and other psychiatric disorders are often overlooked
in the general medical population. This measure will ensure that the clinician remembers to evaluate the
patient for the basis of these psychiatric disorders on a yearly basis.
Marsh L. Neuropsychiatric aspects of Parkinson's disease. Psychosomatics. 2000 Jan-Feb;41(1):15-23.
Ravina B, Marder K, Fernandez HH, Friedman JH, McDonald W, Murphy D, Aarsland D, Babcock D,
Cummings J, Endicott J, Factor S, Galpern W, Lees A, Marsh L, Stacy M, Gwinn-Hardy K, Voon V, Goetz C. Diagnostic criteria for psychosis in Parkinson's disease: report of an NINDS, NIMH work group. Mov
Disord. 2007 Jun 15;22(8):1061-8.
Galpern WR, Stacy M. Management of impulse control disorders in Parkinson's disease. Curr Treat Options Neurol. 2007 May;9(3):189-97.
Shulman LM, Taback RL, Rabinstein AA, Weiner WJ. Non-recognition of depression and other non-motor
symptoms in Parkinson's disease. Parkinsonism Relat Disord. 2002 Jan;8(3):193-7.
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator and Denominator.
Performance Numerator (A) includes:
Patients who were assessed for psychiatric disorders or disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at least annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Performance Calculation
A (# of patients mee ting measure criteria)
PD (# of patients in denominator)
Components for this measure are defined as:
# of patients who were assessed for psychiatric disorders or disturbances (e.g.,
psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at
# of patients with a diagnosis of Parkinson's disease
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients with documentation of assessment for psychiatric disorders or disturbances (e.g., psychosis,
depression, anxiety disorder, apathy, or impulse control disorder) at least annually.
D. Patients with no documentation of assessment for psychiatric disorders or disturbances (e.g., psychosis,
depression, anxiety disorder, apathy, or impulse control disorder) at least annually.
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meetin g numerator criteria)
+ D (# of patients NOT me eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients who were assessed for psychiatric disorders or disturbances (e.g.,
psychosis, depression, anxiety disorder, apathy, or impulse control disorder) at
# of patients with no documentation of assessment for psychiatric disorders or
disturbances (e.g., psychosis, depression, anxiety disorder, apathy, or impulse
control disorder) at least annually
# of patients with a diagnosis of Parkinson's disease
Measure Specifications- Psychiatric Disorders or Disturbances Assessment
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper). (Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
AND ICD-9 diagnosis codes: 332.0
Numerator: Patients who were assessed for psychiatric disorders or disturbances (e.g., psychosis, depression,
anxiety disorder, apathy, or impulse control disorder) at least annually.
Report the CPT Category II,
Psychiatric Disorders or Disturbances Assessment 3700F.
Denominator Exclusion(s): None.
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure # 3: Cognitive Impairment or Dysfunction Assessment
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients who were assessed for cognitive impairment or dysfunction at least annually.
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
No exclusions appropriate for this measure.
Measure: All patients with a diagnosis of Parkinson's disease who were assessed for cognitive impairment or
dysfunction at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
The Mini-Mental State Examination (MMSE) and the Cambridge Cognitive Examination (CAM Cog) should
be considered as screening tools for dementia in patients with PD (Level B). AAN QSS (April 2006)
All veterans with PD should be reassessed for complications of PD (including, but not limited to functional
status, excessive daytime somnolence, speech and swallowing difficulties, dementia, depression, and psychosis) at least on an annual basis. Cheng #10 (Reassessment for complications for PD) 2004
AAN QSS Mental (April 2006) Miyasaki JM, Shannon K, Voon V, Ravina B, Kleiner-Fisman G, Anderson K,
Shulman LM, Gronseth G, Weiner WJ, Quality Standards Subcommittee of the American Academy of
Neurology. Practice parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson
disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy
of Neurology. Neurology 2006 Apr 11;66(7):996-1002.
Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara.
Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004
Rationale for the Measure:
Parkinson's disease is associated with cognitive impairment. It is important to assess patients with Parkinson's disease on an annual basis with regard to their cognitive abilities. Clinically significant cognitive difficulties may
be present early on in the disease course, but dementia may emerge and be diagnosed later in the course of the
disease. However, the insidious onset of cognitive impairment/dementia often occurs over a prolonged
period of time. Emerging cognitive impairment has limited treatment, but is important to identify in terms of
the patient's care and responsibilities within the home, socially, or in the work place.
Factor, S. Weiner, W. Parkinson's Disease: Diagnosis and Clinical Management. 2002
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator and Denominator.
Performance Numerator (A) includes:
Patients who were assessed for cognitive impairment or dysfunction at least annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Performance Calculation
A (# of patients mee ting measure criteria)
PD (# of patients in denominator)
Components for this measure are defined as:
# of patients who were assessed for cognitive impairment or dysfunction at least
# of patients with a diagnosis of Parkinson's disease
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients with documentation of assessment for cognitive impairment or dysfunction at least annually.
D. Patients with no documentation of assessment for cognitive impairment or dysfunction at least annually.
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meetin g numerator criteria)
+ D (# of patients NOT me eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients who were assessed for cognitive impairment or dysfunction at least
# of patients with no documentation of assessment for cognitive impairment or
dysfunction at least annually
# of patients with a diagnosis of Parkinson's disease
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Measure Specifications: Cognitive Impairment or Dysfunction Assessment
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patients who were assessed for cognitive impairment or dysfunction at least annually.
Report the CPT Category II,
Cognitive Impairment or Dysfunction Assessment 3720F.
Denominator Exclusion(s): None.
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure #4: Querying about Symptoms of Autonomic Dysfunction
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients (or caregiver(s), as appropriate) who were queried about symptoms of autonomic
dysfunction (e.g., orthostatic hypotension, constipation, urinary urgency/incontinence and fecal incontinence,
urinary retention requiring catheterization, or persistent erectile failure) at least annually.
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not querying patient (or caregiver) about symptoms of
autonomic dysfunction at least annually (e.g., patient is unable to respond and no informant is
Measure: All patients with a diagnosis of Parkinson's disease (or caregivers, as appropriate) who were queried
about symptoms of autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary
urgency/incontinence and fecal incontinence, urinary retention requiring catheterization, or persistent erectile
failure) at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
Determining the presence of the following clinical features in early stages of disease should be considered to
distinguish PD from other parkinsonian syndromes: 1) falls at presentation and early in the disease course, 2)
poor response to levodopa, 3) symmetry at onset, 4) rapid progression (to Hoehn and Yahr stage 3 in 3 years),
5) lack of tremor, and 6) dysautonomia (urinary urgency/incontinence and fecal incontinence, urinary
retention requiring catheterization, persistent erectile failure, or symptomatic orthostatic hypotension) (Level
B) AAN QSS PD (April 2006)
People with PD should be treated appropriately for the following autonomic disturbances:
-urinary dysfunction; weight loss; dysphagia; constipation; erectile dysfunction; orthostatic hypotension;
excessive sweating; sialorrhoea (Level D) NICE GL35 (Jun 2006)
All veterans with PD should be reassessed for complications of PD (including, but not limited to functional
status, excessive daytime somnolence, speech and swallowing difficulties, dementia, depression, and psychosis)
at least on an annual basis. Cheng #10 (Reassessment for complications for PD) 2004
Cheng Domain 3: Management of non-motor complications indicators (treatment of urologic symptoms;
sildenafil for erectile dysfunction, orthostatic hypotension-medication treatment, orthostatic hypotension
behavioral treatment, antiparkinsonian medications and daytime sleepiness, assessment for excessive daytime
somnolence, excessive daytime somnolence and driving restrictions, assessment of driving ability in PD
patients, treatment of swallowing difficulty, treatment of speech difficulty, botulinum toxin for drooling)
AAN QSS PD Diag. (April 2006) Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth G, Weiner
WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11;66(7):968-75.
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary
Care (2006) London: Royal College of Physicians
Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara.
Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004
(P136-150)
Rationale for the Measure:
Autonomic dysfunction is common in Parkinson's disease and manifests most commonly as orthostatic hypotension (45%), constipation (70%), urinary dysfunction (40%), and erectile dysfunction (55%). These
symptoms can be disabling. Orthostasis can lead to syncope and secondary injury and may be the result of
disease or therapy. Adjustments in medications or addition of pressor agents can be very effective in treating
this problem. Constipation may be the result of medication (particularly anticholinergics or amantadine) or
disease. The extreme effect may be bowel obstruction, which is extremely serious. This manifestation should
be treated aggressively. Urinary difficulties are disabling (preventing patients from leaving home) and
embarrassing to patients and include increased frequency, urgency, incomplete emptying, and obstruction.
These difficulties could be due to medications (anticholinergics or amantadine), Parkinson's disease, or other ailments afflicting the elderly. Proper referral to a urologist would be important. Erectile dysfunction may be
medication- or disease-related and could be addressed with medication adjustment or consultation with
urology. Addressing these issues will have a large impact on morbidity and mortality and prevent
hospitalizations. This would in turn reduce costs of caring for Parkinson's disease patients.
Chaudhuri KR, Healy DG, Schapira AH. Non-motor symptoms of Parkinson's disease: diagnosis and
management. Lancet Neurol. 2006 Mar; 5(3):235-45.
Magerkurth C, Schnitzer R, Braune S. Symptoms of autonomic failure in Parkinson's disease: prevalence and
impact on daily life. Clin Auton Res. 2005 Apr; 15(2):76-82.
Allcock LM, Ullyart K, Kenny RA, Burn DJ. Frequency of orthostatic hypotension in a community based
cohort of patients with Parkinson's disease. J Neurol Neurosurg Psychiatry. 2004 Oct;75(10):1470-1.
Singer C, Weiner WJ, Sanchez-Ramos JR. Autonomic dysfunction in men with Parkinson's disease. Eur
Neurol. 1992; 32(3):134-40.
Edwards LL, Pfeiffer RF, Quigley EM, Hofman R, Balluff M. Gastrointestinal symptoms in Parkinson's
disease. Mov Disord. 1991;6(2):151-6
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patients (or caregiver(s), as appropriate) who were queried about symptoms of autonomic dysfunction (e.g.,
orthostatic hypotension, constipation, urinary urgency/incontinence and fecal incontinence, urinary retention
requiring catheterization, or persistent erectile failure) at least annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Denominator Exclusion (C) includes:
Documentation of medical reason for not querying patient (or caregiver(s), as appropriate) about
symptoms of autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary
urgency/incontinence and fecal incontinence, urinary retention requiring catheterization, or persistent
erectile failure) at least annually.
Performance Calculation
A (# of patients mee ting measure criteria)
PD (# of patients in denominator)-C (# o
f patients with valid denominator exclusions)
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) queried about symptoms of autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary
urgency/incontinence and fecal incontinence, urinary retention requiring
catheterization, or persistent erectile failure) at least annually
# of patients with a diagnosis of Parkinson's disease
# of patients with valid medical reason(s) for not being queried (or a caregiver not being queried) about symptoms of autonomic dysfunction (e.g., orthostatic
hypotension, constipation, urinary urgency/incontinence and fecal incontinence,
urinary retention requiring catheterization, or persistent erectile failure) at least
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients with documentation of being queried (or a caregiver being queried, as appropriate) about
symptoms of autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary
urgency/incontinence and fecal incontinence, urinary retention requiring catheterization, or persistent erectile
failure) at least annually.
C. Patients with documentation of medical reason for not being queried (or a caregiver not being queried)
about symptoms of autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary urgency/incontinence and fecal incontinence, urinary retention requiring catheterization, or persistent erectile
failure) at least annually.
D. Patients with no documentation of being queried (or a caregiver being queried) about symptoms of
autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary urgency/incontinence and fecal
incontinence, urinary retention requiring catheterization, or persistent erectile failure) at least annually.
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Reporting Calculation
A (# of patients meeting numerator criteria ) + C (# of patients with valid exclusions)
+ D (# of patients NOT me eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) queried about symptoms of autonomic dysfunction (e.g., orthostatic hypotension, constipation, urinary
urgency/incontinence and fecal incontinence, urinary retention requiring
catheterization, or persistent erectile failure) at least annually
# of patients with valid medical reason(s) for not being queried (or a caregiver
not being queried) about symptoms of autonomic dysfunction (e.g., orthostatic
hypotension, constipation, urinary urgency/incontinence and fecal incontinence, urinary retention requiring catheterization, or persistent erectile failure) at least
# of patients with no documentation of being queried (or a caregiver being
queried) about symptoms of autonomic dysfunction (e.g., orthostatic
hypotension, constipation, urinary urgency/incontinence and fecal incontinence,
urinary retention requiring catheterization, or persistent erectile failure) at least
# of patients with a diagnosis of Parkinson's disease
Measure Specifications: Querying about Symptoms of Autonomic Dysfunction
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patients (or caregiver(s), as appropriate) who were queried about symptoms of autonomic
dysfunction (e.g., orthostatic hypotension, constipation, urinary urgency/incontinence and fecal incontinence,
urinary retention requiring catheterization, or persistent erectile failure) at least annually.
Report the CPT Category II,
Querying about Symptoms of Autonomic Dysfunction 4326F.
Denominator Exclusion(s): Documentation of medical reason for not querying patient (or caregiver) about
symptoms of autonomic dysfunction (e.g., patient is unable to respond and no informant is available).
Append modifier to CPT II code:
4326F-1P.
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure #5: Querying About Sleep Disturbances
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients (or caregiver(s), as appropriate) who were queried about sleep disturbances at least
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not querying patient (or caregiver) about sleep disturbances
(e.g., patient is unable to respond and no informant is available).
Measure: All patients with a diagnosis of Parkinson's disease (or caregivers, as appropriate) who were
queried about sleep disturbances at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
A full sleep history should be taken from people with PD who report sleep disturbance (Level D) NICE GL35 (Jun 2006)
Good sleep hygiene should be advised in people with PD with any sleep disturbance and includes:
avoidance of stimulants (for example, coffee tea, caffeine) in the evening; establishment of a regular pattern of
sleep; comfortable bedding and temperature; provision of assistive devices, such as a bed lever or rails to aid
with moving and turning, allowing the person to get more comfortable; restriction of daytime siestas; advice
about taking regular and appropriate exercise to induce better sleep; a review of all medication and avoidance
of any drugs that may affect sleep or alertness, or may interact with other medication (for example, selegiline, antihistamines, H2 antagonists, antipsychotics and sedatives) NICE GL35 (June 2006)
All veterans with PD should be reassessed for complications of PD (including, but not limited to functional
status, excessive daytime somnolence, speech and swallowing difficulties, dementia, depression, and psychosis)
at least on an annual basis. Cheng #10 (Reassessment for complications for PD) 2004
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary Care (2006) London: Royal College of Physicians
Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara.
Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004
Rationale for the Measure:
Sleep disorders are common in Parkinson's disease and most commonly include sleep fragmentation (80%),
restless legs syndrome (20%), REM behavior sleep disorder (>40%), and excessive daytime sleepiness ( 50%).
Sleep fragmentation could relate to motor symptoms such as tremor and dystonia, restless legs syndrome,
depression, anxiety, agitation, urinary frequency, or medication (most notably selegiline but also dopamine
agonists). Several approaches to effective therapy are available. Excessive daytime sleepiness could result in
sleep attacks or unintended sleep episodes. Such episodes have been described in various situations, including while driving a car. Excessive daytime sleepiness may result from medication (dopamine agonists), dementia,
psychosis, or poor nocturnal sleep hygiene and is generally more common in advanced Parkinson's disease.
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Medication adjustment and the use of stimulants may be warranted. REM behavior disorder is defined by the
patient acting out dreams. The result could be either the patient or spouse moving to a different bedroom.
This syndrome is treated with benzodiazepines and other medications. Assessing sleep would be expected to lead to improved morbidity and function.
Comella, C. Sleep disorders in Parkinson's disease. Curr Treat Options Neurol. 2008 May;10(3):215-21.
Adler CH, Thorpy MJ. Sleep issues in Parkinson's disease. Neurology. 2005 Jun 28;64(12 Suppl 3):S12-20.
Iranzo A, Santamaría J, Rye DB, Valldeoriola F, Martí MJ, Muñoz E, Vilaseca I, Tolosa E. Characteristics of idiopathic REM sleep behavior disorder and that associated with MSA and PD. Neurology. 2005 Jul
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patients (or caregiver(s), as appropriate) who were queried about sleep disturbances at least annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Denominator Exclusion (C) includes:
Documentation of medical reason for not querying patient (or caregiver) about sleep disturbances at
Performance Calculation
A (# of patients mee ting measure criteria)
PD (# of patients in denominator)-C (# o
f patients with valid denominator exclusions)
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) queried about sleep disturbances at
# of patients with a diagnosis of Parkinson's disease
# of patients with valid medical reason(s) for not being queried (or a caregiver
not being queried) about sleep disturbances at least annually
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients with documentation of being queried (or a caregiver being queried) about sleep disturbances at
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
C. Patients with documentation of medical reason for not being queried (or a caregiver not being queried)
about sleep disturbances at least annually.
D. Patients with no documentation of being queried (or a caregiver being queried) about sleep disturbances at
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meeting numerator crite
ria) + C (# of patients with valid exclusions)
+ D (# of patients NOT me
eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) queried about sleep disturbances at least annually
# of patients with valid medical reason(s) for not being queried (or a caregiver
not being queried) about sleep disturbances at least annually.
# of patients with no documentation of being queried (or a caregiver being
queried) about sleep disturbances at least annually
# of patients with a diagnosis of Parkinson's disease
Measure Specifications: Querying about Sleep Disturbances
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patients (or caregiver(s), as appropriate) who were queried about sleep disturbances at least
Report the CPT Category II,
Querying about Sleep Disturbances 4328F.
Denominator Exclusion(s): Documentation of medical reason for not querying patient (or caregiver) about
sleep disturbances (e.g., patient is unable to respond and no informant is available).
Append modifier to CPT II code:
4328F-1P.
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure #6: Querying about Falls
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patient visits with patient (or caregiver(s), as appropriate) queried about falls.
Denominator: All visits for patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not querying a patient (or caregiver) about falls (e.g., patient is
unable to respond and no informant is available).
Measure: All visits for patients with a diagnosis of Parkinson's disease where patients (or caregivers, as
appropriate) were queried about falls.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
Determining the presence of the following clinical features in early stages of disease should be considered to distinguish PD from other parkinsonian syndromes: 1) falls at presentation and early in the disease course, 2)
poor response to levodopa, 3) symmetry at onset, 4) rapid progression (to Hoehn and Yahr stage 3 in 3 years),
5) lack of tremor, and 6) dysautonomia (urinary urgency/incontinence and fecal incontinence, urinary
retention requiring catheterization, persistent erectile failure, or symptomatic orthostatic hypotension) (Level
B) AAN QSS PD (April 2006)
All veterans with PD should have documentation that they were asked at least annually about the occurrence
of falls. (4 impact outcomes; 4 room for improvement; 3 overall utility rating) Cheng #10 2004 (Annual assessment about falls)
AAN QSS PD Diag. (April 2006) Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth G, Weiner
WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: diagnosis
and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11;66(7):968-75.
Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara. Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004
Rationale for the Measure:
Falls represent a significant risk for injury and can lead to real emergencies (head injury, hip fracture, etc).
Eighty percent of falls in Parkinson's disease patients are due to freezing and postural instability. After 8 years
of Parkinson's disease, 46% of patients fall at least once and 33% are recurrent fallers. Beyond 8 years of disease, 70% fall at least once and 50% are recurrent fallers. In one study that controlled for age, gender,
severity of disease, and number of falls in previous years, 46% fell over a 3-month period and 21% of these
were new fallers. Approximately 25% of falls result in injury. The most important risk factor for falling is a
prior fall. Assessing patients regularly for falls could allow for preventative measures, including physical
therapy, medication adjustments, and use of assistive devices such as canes and walkers. Prevention of falls
could have a large impact on morbidity and mortality as well as health care costs.
Michalowska M, Fiszer U, Krygowska-Wajs A, Owczarek K. Falls in Parkinson's disease. Causes and impact
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
on patients' quality of life. Funct Neurol 2005;20(4):163-168.
Balash Y, Peretz C, Leibovich G, Herman T, Hausdorff JM, Giladi N. Falls in outpatients with Parkinson's disease: frequency, impact and identifying factors. J Neurol 2005;252(11):1310-1315.
Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing of gait in Parkinson's disease: a review of two interconnected, episodic phenomena. Mov Disord 2004;19(8):871-884.
Grimbergen YA, Munneke M, Bloem BR. Falls in Parkinson's disease. Curr Opin Neurol 2004;17(4):405-415.
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patient visits with patient (or caregiver, as appropriate) queried about falls.
Performance Denominator (PD) includes:
All visits for patients with a diagnosis of Parkinson's disease.
Denominator Exclusions (C) include:
Documentation of medical reason for not querying patient (or caregiver) about falls.
Performance Calculation
A (# of patient visits meeting measure criteria)
PD (# of patient visits in denominator) – C (# o
f patient visits with valid denominator exclusions)
Components for this measure are defined as:
# of patient visits where patient (or caregiver(s), as appropriate) was queried
# of patient visits for patients with a diagnosis of Parkinson's disease
# of patient visits with valid medical reason(s) for not querying the patient (or caregiver) about falls
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Reporting Numerator includes each of the following instances:
A. Patient visits with a documentation of patient (or caregiver(s), as appropriate) being queried about falls.
C. Patient visits with documentation of medical reason(s) for not querying the patient (or caregiver) about
falls.
D. Patient visits with no documentation of patient (or caregiver) being queried about falls.
Reporting Denominator (RD) includes:
RD. All visits for patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patient visits meeting numerator crite
ria) + C (# of patient visits with valid exclusions)
+ D (# of patient visits NOT
meeting numerator criteria)
RD (# of patient visit s in denominator)
Components for this measure are defined as:
# of patient visits with patient (or caregiver, as appropriate) being queried about
# of patient visits with documentation of medical reason for not querying the
patient (or caregiver) about falls
# of patient visits with no documentation of the patient (or caregiver) being
queried about falls
# of patient visits with a diagnosis of Parkinson's disease
Measure Specifications- Querying about Falls
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.) Denominator (Eligible Population): All visits for patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patients (or caregiver(s), as appropriate) queried about falls.
Report the CPT Category II,
Querying about Falls 6080F .
Denominator Exclusion: Documentation of medical reason(s) for not querying the patient (or caregiver)
about falls (e.g., patient is unable to respond and no informant is available).
Append modifier to CPT Category II code:
6080F-1P
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure # 7: Parkinson's Disease Rehabilitative Therapy Options
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical,
occupational, or speech therapy) discussed at least annually.
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not discussing rehabilitative therapy options with the patient
(or caregiver(s), as appropriate) at least annually (e.g., patient has no known physical disability due to
Parkinson's disease; patient is unable to respond and no informant available).
Measure: All patients with a diagnosis of Parkinson's disease (or caregiver(s), as appropriate) who had
rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
Physiotherapy should be available for people with PD. Particular consideration should be given to: -gait re-education, improvement of balance and flexibility; enhancement of aerobic capacity; improvement of
movement initiation; improvement of functional independence, including mobility and activities of daily living;
provision of advice regarding safety in the home environment. (Level B) NICE GL35 (Jun 2006)
Occupational therapy should be available for people with PD. Particular consideration should be given to:
-maintenance of work and family roles, home care and leisure activities; improvement and maintenance of
transfers and mobility; improvement of personal self-care activities, such as eating, drinking, washing, and
dressing; cognitive assessment ad appropriate intervention. (Level D) NICE GL35 (Jun 2006) Speech and language therapy should be available for people with PD. Particular consideration should be given
to: -Improvement of vocal loudness and pitch range, including speech therapy programs such as Lee
Silverman Voice Treatment (LSVT) (Level B) NICE GL35 (Jun 2006)
All veterans with PD who have impairment of ADLs or in walking ability should be referred for physical therapy. Cheng et al. #9 (Referral for physical therapy) 2004
For patients with Parkinson's disease complicated by dysarthria, speech therapy may be considered to improve
speech volume (Level C). Different exercise modalities, including multidisciplinary rehabilitation, active music
therapy, treadmill training, balance training, and "cued" exercise training are probably effective in improving
functional outcomes for patients with Parkinson's disease. For patients with Parkinson's disease, exercise
therapy may be considered to improve function (Level C). AAN QSS Neuro Alt (April 2006)
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary
Care (2006) London: Royal College of Physicians
Cheng E, Siderowf A, Swarztrauber K, Eisa M, Lee M and Vickrey B. Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004 (P136-150)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
AAN QSS Neuro Alt (April 2006) Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner
WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): report of
the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11;
66(7):976-82.
Rationale for the Measure:
For those patients with Parkinson's disease who have impaired activities of daily living, therapy options such
as physical, occupational, and speech therapy should be offered. Rehabilitative therapies play an important role
in improving function and quality of life for these patients. Symptomatic therapy can provide benefit for
many years. Patients with Parkinson's disease commonly develop dysarthria.
AAN QSS Neuro Alt (April 2006) Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner
WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter:
neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): report of
the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006 Apr
11;66(7):976-82.
Factor, S. Weiner, W. Parkinson's Disease: Diagnosis and Clinical Management. 2002
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patients (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or
speech therapy) discussed at least annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Denominator Exclusion (C) includes:
Documentation of medical reason for not discussing rehabilitative therapy options (e.g., physical,
occupational, or speech therapy) at least annually.
Performance Calculation
A (# of patients mee ting measure criteria)
PD (# of patients in denominator)-C (# o
f patients with valid denominator exclusions)
Components for this measure are defined as:
# of patients (or caregiver(s), as appropriate) who had rehabilitative therapy
options (e.g., physical, occupational, or speech therapy) discussed at least annually
# of patients with a diagnosis of Parkinson's disease
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
# of patients with valid medical reason(s) for not discussing rehabilitative therapy
options (with patient or caregiver) (e.g., physical, occupational, or speech therapy) at least annually
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients with documentation of rehabilitative therapy options discussed with the patient (or caregiver(s), as
appropriate) (e.g., physical, occupational, or speech therapy) at least annually.
C. Patients with documentation of medical reason for not discussing rehabilitative therapy options with the
patient (or caregiver(s), as appropriate) (e.g., physical, occupational, or speech therapy) at least annually.
D. Patients with no documentation of discussing rehabilitative therapy options with the patient (or
caregiver(s), as appropriate) (e.g., physical, occupational, or speech therapy) at least annually.
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meeting numerator criteria ) + C (# of patients with valid exclusions)
+ D (# of patients NOT me eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients (or caregiver(s), as appropriate) who had rehabilitative therapy
options (e.g., physical, occupational, or speech therapy) discussed at least annually
# of patients with valid medical reason(s) for not discussing rehabilitative therapy options with patient (or caregiver(s), as appropriate) (e.g., physical, occupational,
or speech therapy) at least annually
# of patients with no documentation of discussing rehabilitative therapy options
with patient (or caregiver(s), as appropriate) (e.g., physical, occupational, or
speech therapy) at least annually
# of patients with a diagnosis of Parkinson's disease
Measure Specifications: Parkinson's Disease Rehabilitative Therapy Options
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
ICD-9 diagnosis codes: 332.0
Numerator: Patients (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical,
occupational, or speech therapy) discussed at least annually.
Report the CPT Category II,
Parkinson's Disease Rehabilitative Therapy Options 4400F.
Denominator Exclusion(s): Documentation of medical reason(s) for not discussing rehabilitative therapy
options with patient (or caregiver, as appropriate) (e.g., physical, occupational, or speech therapy) at least annually (e.g., patient has no known physical disability due to Parkinson's disease; patient is unable to respond
and no informant available).
Append modifier to CPT II code:
4400F-1P
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure # 8: Parkinson's Disease Related Safety Issues Counseling
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients (or caregiver(s), as appropriate) who were counseled about context-specific safety issues
appropriate to the patient's stage of disease (e.g., injury prevention, medication management, or driving) at
least annually.
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not counseling the patient (or caregiver) about context-specific
safety issues appropriate to the patient's stage of disease (e.g., patient is unable to respond and no
informant is available)
Measure: All patients with a diagnosis of Parkinson's disease (or caregivers, as appropriate) who were
counseled about context-specific safety issues appropriate to the patient's stage of disease (e.g., injury
prevention, medication management, or driving) at least annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
If a veteran with PD has newly diagnosed dementia, then the diagnosing physician should advise the patient not drive a motor vehicle or request that the Department of Motor Vehicles ( or an equivalent agency) retest
the patient's ability to drive, or refer the patient to a driver's safety course that includes assessment of driving
ability (consistent with state laws). Cheng et al. #24 (Advising against driving in dementia) 2004
All veterans with PD should be asked about their ability to operate a motor vehicle. Cheng et al. 2004. #30
(Assessment of driving ability in PD patients)
All veterans with PD who report excessive daytime sleepiness should be instructed not to drive a motor vehicle. Cheng et al. 2004 #29 (Excessive daytime somnolence and driving restrictions)
If a veteran with PD or his or her family expresses concern about driving safely, then the clinician should
advise the patient not to drive a motor vehicle and/or request the DMV retest the patients' ability to drive,
and/or refer the patient to a driver's safety course that includes assessment of driving ability, in accordance
with state laws. Cheng #46 (Actions regarding driving safety concerns)
Cheng E, Siderowf A, Swarztrauber K, Eisa M, Lee M and Vickrey B. Development of Quality of Care
Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004 (P136-150)
Rationale for the Measure:
There are several scenarios where safety issues are important in Parkinson's disease. One relates to balance
and the risk of falling. Patients with Parkinson's disease need to be counseled regarding the dangers of
climbing on ladders and chairs, climbing and descending stairs, and walking on uneven terrain because of the dangers of falling. Twenty-five percent ( 25%) of falls result in injury. Medication can cause adverse effects
such as orthostasis and excessive daytime sleepiness that result in concerns about safety. Patients need to be
counseled on these issues. Patients with Parkinson's disease experience a number of functional difficulties
that may affect driving safety. Motor function, visual perceptive activities, reaction time, attention
maintenance, sleep disorders, and information processing are all abnormal in patients with Parkinson's disease,
which leads to an increase in accidents per mile driven. Dementia is often associated with Parkinson's disease
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
adds another dimension to the problem. In the mild-to-moderate stages of dementia, some patients remain
competent whereas others are not. Many continue to drive even in advanced stages because of the issue of
independence and the social impact of cessation. The responsibility for determining driving competence in early-to-mid-duration patients with Parkinson's disease is the responsibility of patients, families, and
physicians. Driving should be discussed with all patients, and referral for a proper driving assessment by an
experienced driver rehabilitation specialist should be considered if necessary. Those who continue to drive
should be assessed regularly because the disease and its therapies change with time.
Factor SA, Weiner WJ. Driving. In: Parkinson's Disease: Diagnosis and Clinical Management. Second Edition.
Factor SA, Weiner WJ, eds. Demos Publishing, New York, NY. 2008. pp: 779-790.
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patients (or caregiver(s), as appropriate) who were counseled about context-specific safety issues appropriate
to the patient's stage of disease (e.g., injury prevention, medication management, or driving) at least annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Denominator Exclusion (C) includes:
Documentation of medical reason for not counseling patient (or caregiver) about context-specific
safety issues appropriate to the patient's stage of disease (e.g., injury prevention, medication
management, or driving) at least annually.
Performance Calculation
A (# of patients mee ting measure criteria)
PD (# of patients in denominator)-C (# o
f patients with valid denominator exclusions)
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) who were counseled about context-
specific safety issues appropriate to the patient's stage of disease (e.g., injury prevention, medication management, or driving) at least annually
# of patients with a diagnosis of Parkinson's disease
# of patients (or caregivers) with valid medical reason(s) for not being counseled
about context-specific safety issues appropriate to the patient's stage of disease
(e.g., injury prevention, medication, management, or driving) at least annually
Calculation for Reporting
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients (or caregivers, as appropriate) who were counseled about context-specific safety issues appropriate
to the patient's stage of disease (e.g., injury prevention, medication management, or driving) at least annually.
C. Patients with documentation of medical reason for not being counseled(or caregivers being counseled)
about context-specific safety issues appropriate to the patient's stage of disease (e.g., injury prevention,
medication management, or driving) at least annually.
D. Patients with no documentation of being counseled (or caregivers being counseled) about context-specific
safety issues appropriate to the patient's stage of disease (e.g. injury prevention, medication management, or driving) at least annually.
Reporting Denominator (RD) Includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meeting numerator criteria ) + C (# of patients with valid exclusions)
+ D (# of patients NOT me eting numerator criteria)
RD (# of patients
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) who were counseled about context-specific safety issues appropriate to the patient's stage of disease (e.g. injury
prevention, medication management, or driving) at least annually
# of patients with valid medical reason(s) for not being counseled (or caregivers
not being counseled) about context-specific safety issues appropriate to the
patient's stage of disease (e.g., injury prevention, medication, management, or
driving) at least annually
# of patients with no documentation of being counseled (or caregivers being
counseled) about context-specific safety issues appropriate to the patient's stage
of disease (e.g. injury prevention, medication management, or driving) at least
# of patients with a diagnosis of Parkinson's disease
Measure Specifications: Parkinson's Disease Related Safety Issues Counseling
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Numerator: Patients (or caregivers, as appropriate) who were counseled about context-specific safety issues
appropriate to the patient's stage of disease (e.g., injury prevention, medication management, or driving) at least annually.
Report the CPT Category II,
Parkinson's Disease Related Safety Issues Counseling 6090F.
Denominator Exclusion(s): Documentation of medical reason(s) for not counseling the patient (or caregiver,
as appropriate) about context-specific safety issues appropriate to the patient's stage of disease (e.g., injury
prevention, medication management, or driving) at least annually (e.g., patient is unable to respond and no
informant is available).
Append modifier to CPT II code:
6090F-1P.
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure # 9: Querying about Parkinson's Disease Medication-Related Motor Complications
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patient visits with patient (or caregiver(s), as appropriate) queried about Parkinson's disease
medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
Denominator: All visits for patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not querying patient (or caregiver) about Parkinson's disease
medication-related motor complications (e.g., patient is not on a Parkinson's disease medication;
patient is unable to respond and no informant is available)
Measure: All visits for patients with a diagnosis of Parkinson's disease where patients (or caregiver(s), as
appropriate) were queried about Parkinson's disease medication-related motor complications (e.g., wearing off,
dyskinesia, or off-time).
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
MAO-B inhibitors may be used to reduce motor fluctuations in people with later PD. (Level A) NICE GL35
Catechol-O-methyl transferase (COMT) inhibitors may be used to reduce motor fluctuations in people with
later PD. (Level A) NICE GL35 (June 2006)
Modified-release levodopa preparations may be used to reduce motor complications in people with later PD,
but should not drugs of first choice. (Level B) NICE GL35 (June 2006) Dopamine agonists may be used to reduce motor fluctuations in people with later PD. (Level A) NICE GL35
-Adjust levodopa dosing. In an early phase, when motor fluctuations are just becoming apparent, adjustments
in the frequency of levodopa dosing during the day, tending to achieve four to six daily doses, might attenuate
the wearing-off (good practice point). EFNS PD Part II (Nov. 2006) - Switch from standard levodopa to controlled release (CR) formulation. CR formulations of levodopa can
also improve wearing-off (level C). EFNS PD Part II (Nov. 2006)
- Add catechol-O-methyltransferase (COMT) inhibitors or monoamine oxidase isoenzyme type B (MAO-B)
inhibitors. No recommendations can be made on which treatment should be chosen first – on average, all
reduce OFF time by about 1 to 1.5 h/day. The only published direct comparison (level A) showed no
difference between entacapone and rasagiline. EFNS PD Part II (Nov. 2006)
- Add dopamine agonists. Oral dopamine agonists are efficacious in reducing OFF time in patients
experiencing wearing-off. Currently, no dopamine agonist has proven better than another, but switching from one agonist to another can be helpful in some patients (level B/C). EFNS PD Part II (Nov. 2006)
- Add amantadine or an anticholinergic. In patients with disabling recurrent OFF symptoms that fail to
improve further with the above mentioned strategies, the addition of an anticholinergic (in younger patients),
or amantadine, may improve symptoms in some cases (good practice point). EFNS PD Part II (Nov. 2006)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Peak-Dose Dyskinesia
Add amantadine– most studies use 200 to 400 mg/day. The benefit may last <8 months. (Level A) EFNS PD Part II (Nov. 2006)
Reduce individual levodopa dose size, at the risk of increasing OFF time. The latter can be compensated for
by increasing the number of daily doses of levodopa or increasing the doses of a dopamine agonist. (Level C)
EFNS PD Part II (Nov 2006)
Discontinue or reduce dose of MAO-B inhibitors or COMT inhibitors at the risk of worsening wearing-off.
(GPP) EFNS PD Part II (Nov 2006)
Add atypical antipsychotics, clozapine with doses ranging between 12.5 and 75 mg/day up to 200 mg/day
(Level A) EFNS PD Part II (Nov 2006) Add quetiapine (Level C) EFNS PD Part II (Nov 2006)
Amandatine may be considered to reduce dyskinesia (Level C) AANQSS PD Dyskin (April 2006)
Entacapone and rasagiline should be offered to reduce off time (Level A) AANQSS PD Dyskin (April 2006)
Pergolide, Pramipexole, ropinirole, and Tolcapone should be considered to reduce off time. (Level B)
AANQSS PD Dyskin (April 2006) Apomorphine, cabergoline, and selegiline may be considered to reduce off time. (Level C) AAN QSS PD
Dyskin (April 2006)
The available evidence does not establish superiority of one medicine over another in reducing off time. (Level
B) AAN QSS PD Dyskin (April 2006)
AAN QSS PD Diag. (April 2006) Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth G, Weiner
WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: diagnosis
and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11;66(7):968-75.
AAN QSS PD Dyskin (April 2006) Pahwa R, Factor SA, Lyons KE, Ondo WF, Gronseth G, Bronte-Stewart
H, Hallet M, Miyasaki J, Stevens J, and Weiner WJ. Practice Parameter: Treatment of Parkinson's disease with
motor fluctuations and dyskinesia (an evidence-based review): Report of the quality Standards Subcommittee of the American Academy of Neurolgoy. Neurology 2006 April 2;66;983-995
EFNS PD Part I (Nov. 2006)
Horstink M, Tolosa E, Bonuccelli U, Deuschl G, Friedman A, Kanovsky P, Larsen JP, Lees A, Oertel W,
Poewe W, Rascol O, Sampaio C, European Federation of Neurological Societies, Movement Disorder Society-
European Section. Review of the therapeutic management of Parkinson's disease. Report of a joint task force
of the European Federation of Neurological Societies and the Movement Disorder Society-European Section.
Part I: early (uncomplicated) Parkinson's disease. Eur J Neurol 2006 Nov;13(11):1170-85. EFNS PD Part II (Nov. 2006)
Horstink M, Tolosa E, Bonuccelli U, Deuschl G, Friedman A, Kanovsky P, Larsen JP, Lees A, Oertel W,
Poewe W, Rascol O, Sampaio C, European Federation of Neurological Societies, Movement Disorder Society-
European Section. Review of the therapeutic management of Parkinson's disease Parkinson's disease. Report
of a joint task force of the EFNS and the MDS-ES. Part II: late (complicated) Parkinson's disease. Eur J
Neurol 2006 Nov;13(11):1186-202.
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary
Care (2006) London: Royal College of Physicians
Rationale for the Measure:
Dopaminergic therapies are commonly accompanied by motor fluctuations, including off time (periods of
return of Parkinson's disease symptoms when medication effect wears off) and dyskinesia (drug-induced
involuntary movements, including chorea and dystonia) in most patients. It is important to query patients about these problems because medication adjustments and the addition of adjunctive medications can often
ameliorate the problem(s). With these adjustments, the patient's quality of life can be improved.
AAN QSS PD Dyskin (April 2006) Pahwa R, Factor SA, Lyons KE, Ondo WF, Gronseth G, Bronte-Stewart
H, Hallet M, Miyasaki J, Stevens J, and Weiner WJ. Practice Parameter: Treatment of Parkinson's disease with
motor fluctuations and dyskinesia (an evidence-based review): Report of the quality Standards Subcommittee
of the American Academy of Neurology. Neurology 2006 April 2;66;983-995
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patient visits with patient (or caregiver(s), as appropriate) queried about Parkinson's disease medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
Performance Denominator (PD) includes:
All visits for patients with a diagnosis of Parkinson's disease.
Denominator Exclusions (C) include:
Documentation of medical reason for not querying patient (or caregiver) about Parkinson's disease
medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
Performance Calculation
A (# of patient visits meeting measure criteria)
PD (# of patient visits in denominator) – C (# o
f patient visits with valid denominator exclusions)
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) queried about Parkinson's disease
medication-related motor complications (e.g., wearing off, dyskinesia, or off-time)
# of patient visits for patients with a diagnosis of Parkinson's disease
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
# of patient visits with documentation of valid medical reason(s) for not querying
the patient (or caregiver) about Parkinson's disease medication-related motor complications (e.g., wearing off, dyskinesia, or off-time)
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patient visits with documentation of patient (or caregiver, as appropriate) being queried about Parkinson's
disease medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
C. Patient visits with documentation of medical reason(s) for not querying patient (or caregiver) about
Parkinson's disease medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
D. Patient visits with no documentation of patient (or caregiver) being queried about Parkinson's disease
medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
Reporting Denominator (RD) includes:
RD. All visits for patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patient visits meeting numerator crite
ria) + C (# of patient visits with valid exclusions)
+ D (# of patient visits NOT
meeting numerator criteria)
RD (# of patient visit s in denominator)
Components for this measure are defined as:
# of patient visits where patient (or caregiver, as appropriate) was queried about
Parkinson's disease medication-related motor complications (e.g., wearing off, dyskinesia, or off-time)
# of patient visits with documentation of medical reason for not querying patient
(or caregiver(s), as appropriate) about Parkinson's disease medication-related
motor complications (e.g., wearing off, dyskinesia, or off-time)
# of patient visits with no documentation of patient (or caregiver) being queried about Parkinson's disease medication-related motor complications (e.g., wearing
off, dyskinesia, or off-time)
# of patient visits with a diagnosis of Parkinson's disease
Measure Specifications- Querying about Parkinson's Disease Medication-Related Motor
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Denominator (Eligible Population): All visits for patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patient visits where patient (or caregiver(s), as appropriate) was queried about Parkinson's disease
medication-related motor complications (e.g., wearing off, dyskinesia, or off-time).
Report the CPT Category II,
Querying about Parkinson's Disease Medication-Related Motor Complications
Denominator Exclusion: Documentation of medical reason(s) for not querying the patient (or caregiver)
about Parkinson's disease medication-related motor complications (e.g., wearing off, dyskinesia, or off-time)
(e.g., patient is not on a Parkinson's disease medication; patient is unable to respond and no informant is
Append modifier to CPT Category II code:
4324F-1P
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
PARKINSON'S DISEASE
Measure # 10: Parkinson's Disease Medical and Surgical Treatment Options Reviewed
This measure may be used as an accountability measure.
Clinical Performance Measure
Numerator: Patients (or caregiver(s), as appropriate) who had the Parkinson's disease treatment options
(e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once
Denominator: All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions:
Documentation of medical reason for not reviewing the Parkinson's disease treatment options (e.g.,
non-pharmacological treatment, pharmacological treatment, or surgical treatment) at least once
annually (e.g., the patient is unable to respond and no informant is available)
Measure: All patients with a diagnosis of Parkinson's disease (or caregiver(s), as appropriate who had the
Parkinson's disease treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or
surgical treatment) reviewed at least once annually.
The following clinical recommendation statements are quoted verbatim from the referenced clinical
guidelines and represent the evidence base for the measure:
People with PD should have regular access to the following: -clinical monitoring and medication adjustment; -
a continuing point of contact for support, including home visits when appropriate; -a reliable source of
information about clinical and social matters of concern to people with PD and their carers which may be
provided by a Parkinson's disease nurse specialist. NICE GL35. (June 2006)
With the current evidence it is not possible to decide if the subthalamic nucleus or globus pallidus interna is
the preferred target for deep brain stimulation for people with PD, or whether one form of surgery is more effective or safer than the other. In considering the type of surgery, account should be taken of:-clinical and
lifestyle characteristics of the person with PD; -patient preference, after the patient has been informed of the
potential benefits and; -drawbacks of the different surgical procedures. (Level D) NICE GL35 (June 2006)
NICE National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic
Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary
Care (2006) London: Royal College of Physicians
Rationale for the Measure:
There are many different pharmacological, non-pharmacological, and surgical treatment options available for
patients diagnosed with Parkinson's disease. Within each type of treatment, there are also multiple factors to
be considered when deciding whether a patient with Parkinson's disease is a candidate for the treatment option.
With the advent of newly available pharmacological treatments from many different ongoing clinical trials and
studies, the patient's current medication treatment should be reviewed as therapy-based reviews are updated.
AAN QSS Init. Treatment of Parkinson's Disease (Jan 2002) Miyasaki JM, Martin W, Suchowersky O, Weiner
WJ, Lang AE. Practice parameter: initiation of treatment for Parkinson's disease: an evidence-based review:
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2002 Jan
Anthony E. Lang, Jean-Luc Houeto, Paul Krack, et al. Deep brain stimulation: Preoperative issues
Movement Disorders 2006 June; 21(S14): S171-S196
Data Capture and Calculations:
Calculation for Performance
For performance purposes, this measure is calculated by creating a fraction with the following components:
Numerator, Denominator, and Denominator Exclusions.
Performance Numerator (A) includes:
Patients (or caregivers, as appropriate) who had the Parkinson's disease treatment options (e.g., non-
pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually.
Performance Denominator (PD) includes:
All patients with a diagnosis of Parkinson's disease.
Denominator Exclusions (C) include:
Documentation of medical reason for not reviewing the Parkinson's disease treatment options (e.g.,
non-pharmacological treatment, pharmacological treatment, or surgical treatment) at least once
Performance Calculation
A (# of patients mee
ting measure criteria)
PD (# of patients in denominator) – C (# o
f patients with valid denominator exclusions)
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) who had the Parkinson's disease
treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually
# of patients with a diagnosis of Parkinson's disease
# of patients with valid medical reason(s) for not having the Parkinson's disease
treatment options (e.g., non-pharmacological treatment, pharmacological
treatment, or surgical treatment) reviewed at least once annually
Calculation for Reporting
For reporting purposes, this measure is calculated by creating a fraction with the following components:
Reporting Numerator and Reporting Denominator.
Reporting Numerator includes each of the following instances:
A. Patients (or caregivers, as appropriate) who had the Parkinson's disease treatment options (e.g., non-
pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually.
C. Patients (or caregivers) with documentation of medical reason(s) for not having the Parkinson's disease
treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment)
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
reviewed at least once annually.
D. Patients (or caregivers) with no documentation of having Parkinson's disease treatment options (e.g., non-
pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually.
Reporting Denominator (RD) includes:
RD. All patients with a diagnosis of Parkinson's disease.
Reporting Calculation
A (# of patients meeting numerator crite ria) + C (# of patients with valid exclusions)
+ D (# of patients NOT m eeting numerator criteria)
RD (# of patients in denominator)
Components for this measure are defined as:
# of patients (or caregivers, as appropriate) who had the Parkinson's disease
treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once annually
# of patients (or caregivers) with documentation of medical reason(s) for not
having the Parkinson's disease treatment options (e.g., non-pharmacological
treatment, pharmacological treatment, or surgical treatment) reviewed at least
# of patients (or caregivers) with no documentation of having Parkinson's disease
treatment options (e.g., non-pharmacological treatment, pharmacological
treatment, or surgical treatment) reviewed at least once annually.
# of patients with a diagnosis of Parkinson's disease
Measure Specifications: Parkinson's Disease Medical and Surgical Treatment Options Reviewed
Measure specifications for data sources other than administrative claims will be developed at a later date.
A. Administrative Claims Data
Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper).
(Note: The specifications listed below are those needed for performance calculation.)
Denominator (Eligible Population): All patients with a diagnosis of Parkinson's disease.
CPT ®Procedure Codes: 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99241,
99242, 99243, 99244, 99245, 99304, 99305, 99306, 99307, 99308, 99309, 99310
ICD-9 diagnosis codes: 332.0
Numerator: Patients (or caregiver(s), as appropriate) who had the Parkinson's disease treatment options (e.g.,
non-pharmacological treatment, pharmacological treatment, or surgical treatment) reviewed at least once
Report the CPT Category II,
Parkinson's Disease Medical and Surgical Treatment Options Reviewed 4325F.
Denominator Exclusion(s): Documentation of medical reason(s) for not reviewing the Parkinson's disease
treatment options (e.g., non-pharmacological treatment, pharmacological treatment, or surgical treatment) at
least once annually. (e.g., the patient is unable to respond and no informant is available)
Append modifier to CPT Category II code:
4325F-1P
2009 American Academy of Neurology. All rights reserved. Version 9
AAN Parkinson's Disease Physician Performance Measurement Set
B. Electronic Health Record System (in development)
C. Paper Medical Record (in development)
REFERENCES
1. AAN QSS Init. Treatment PD (Jan 2002) Miyasaki JM, Martin W, Suchowersky O, Weiner WJ, Lang AE. Practice parameter: initiation of treatment for Parkinson's disease: an evidence-based review: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2002 Jan 8; 58(1):11-7.
2. AAN QSS PD Diag. (April 2006) Suchowersky O, Reich S, Perlmutter J, Zesiewicz T, Gronseth G, Weiner WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: diagnosis and prognosis of new onset Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee
of the American Academy of Neurology. Neurology 2006 Apr 11; 66(7):968-75. 3. AAN QSS PD Dyskin (April 2006) Pahwa R, Factor SA, Lyons KE, Ondo WF, Gronseth G, Bronte-Stewart H, Hallet M, Miyasaki J, Stevens J, and Weiner WJ. Practice Parameter: Treatment of Parkinson's disease with motor
fluctuations and dyskinesia (an evidence-based review): Report of the quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006 April 2;66;983-995 4. AAN QSS Mental (April 2006) Miyasaki JM, Shannon K, Voon V, Ravina B, Kleiner-Fisman G, Anderson K,
Shulman LM, Gronseth G, Weiner WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: evaluation and treatment of depression, psychosis, and dementia in Parkinson disease (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11; 66(7):996-1002.
5. AAN QSS Neuro Alt (April 2006) Suchowersky O, Gronseth G, Perlmutter J, Reich S, Zesiewicz T, Weiner WJ, Quality Standards Subcommittee of the American Academy of Neurology. Practice parameter: neuroprotective strategies and alternative therapies for Parkinson disease (an evidence-based review): report of the Quality Standards
Subcommittee of the American Academy of Neurology. Neurology 2006 Apr 11; 66(7):976-82. 6. NICE: National Collaborating Centre for Primary Care. National Collaborating Centre for Chronic Conditions. Parkinson's Disease: National Clinical Guideline for Management in Primary and Secondary Care (2006) London:
Royal College of Physicians 7. EFNS PD Part I (Nov. 2006) Horstink M, Tolosa E, Bonuccelli U, Deuschl G, Friedman A, Kanovsky P, Larsen JP, Lees A, Oertel W, Poewe W,
Rascol O, Sampaio C, European Federation of Neurological Societies, Movement Disorder Society-European Section. Review of the therapeutic management of Parkinson's disease. Report of a joint task force of the European Federation of Neurological Societies and the Movement Disorder Society-European Section. Part I: early (uncomplicated) Parkinson's disease. Eur J Neurol 2006 Nov; 13(11):1170-85.
8. EFNS PD Part II (Nov. 2006) Horstink M, Tolosa E, Bonuccelli U, Deuschl G, Friedman A, Kanovsky P, Larsen JP, Lees A, Oertel W, Poewe W, Rascol O, Sampaio C, European Federation of Neurological Societies, Movement Disorder Society-European Section.
Review of the therapeutic management of Parkinson's disease. Report of a joint task force of the EFNS and the MDS-ES. Part II: late (complicated) Parkinson's disease. Eur J Neurol 2006 Nov; 13(11):1186-202. 9. Cheng Eric, Siderowf Andrew, Swarztrauber Kari, Eisa Mahmood, Lee Martin and Vickrey Barbara. Development of Quality of Care Indicators for Parkinson's disease Movement Disorders Vol. 19, No.2, 2004 (P136-150)
2009 American Academy of Neurology. All rights reserved. Version 9
Source: http://curebraindisease.net/globals/axon/assets/9084.pdf
[Downloaded free from http://www.jcsjournal.org on Tuesday, July 05, 2016, IP: 197.253.33.106] ORIGINAL RESEARCH REPORT Antibiotic susceptibility/resistant gene profiles of Group B streptococci isolates from pregnant women in a tertiary institution in Nigeria Charles J. Elikwu1,2, Oyinlola O. Oduyebo3, Rose I. Anorlu4, Brigitte König5
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