Measure Description
The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had a lumbar discectomy/laminotomy procedure
Instructions
This measure is to be submitted each time a patient undergoes a lumbar discectomy/laminotomy during the denominator identification period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Unique to this measure is the Minimum Process of Care Performance Threshold Requirement. This measure based threshold requires that at least 50% of the denominator eligible patients must have a preoperative and postoperative pain assessment completed. Therefore, if the performance rate for Submission Criteria One is below 50%, the MIPS eligible clinician would not be able to meet the denominator of Submission Criteria Two and this measure CANNOT BE SUBMITTED. CMS anticipates that the sum of change for Submission Criteria Two will be calculated using 100% of procedures that met performance in Submission Criteria One.
NOTE: The standard program requirement of Data Completeness for all denominator eligible procedures (those receiving lumbar discectomy/laminotomy procedures) that must be submitted.
This measure contains elements of a proportion or rate and a simple average of the change in back pain preoperatively to postoperatively among patients having received a lumbar discectomy/laminotomy procedure. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures to be utilized for performance calculation.
A preoperative and postoperative pain assessment using the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 20 weeks) postoperatively for at least 50% of denominator eligible patients receiving a lumbar discectomy/laminotomy is a denominator inclusion criterion to be eligible to submit this performance measure - the average change in preoperative to postoperative pain level (Submission Criteria Two). A MIPS eligible clinician must submit 100% of the population identified with a preoperative and postoperative pain assessment (Performance Met Criteria for Submission Criteria One) of this measure for Submission Criteria Two.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:
1) Patients 18 years of age or older as of January 1 of the denominator identification period who had a lumbar discectomy/laminotomy procedure performed during the denominator identification period
AND
2) Average change (preoperative to three months (6 – 20 weeks) postoperative) in back pain for all eligible patients 18 years of age or older as of January 1 of the denominator identification period who had a lumbar discectomy/laminotomy procedure performed during the denominator identification period and whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively and at three months (6 – 20 weeks) postoperatively
SUBMISSION CRITERIA 1: PATIENTS 18 YEARS OF AGE OR OLDER AS OF JANUARY 1 OF THE DENOMINATOR IDENTIFICATION PERIOD WHO HAD A LUMBAR DISCECTOMY/LAMINOTOMY PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD
Denominator (Submission Criteria 1)
Patients 18 years of age or older as of January 1 of the denominator identification period who had a lumbar discectomy/laminotomy procedure for a diagnosis of disc herniation performed during the denominator identification period
Definition:
Denominator Identification Period - The twelve month period in which eligible patients have a procedure. This allows for enough time for a follow-up assessment to occur during the performance period. The denominator identification period includes dates of procedure (1/1/2018 to 12/31/2018).
Denominator Criteria (Eligible Cases) 1:
Patients aged ≥ 18 years by January 1 of the Denominator Identification Period
AND
Diagnosis for herniated disc (ICD-10-CM): M51.26, M51.27
AND
Patient procedure during the denominator identification period (CPT): 63030
AND NOT
DENOMINATOR EXCLUSION:
Patient had any additional spine procedures performed on the same date as the lumbar discectomy/laminotomy: G9942
Numerator (Submission Criteria 1)
All eligible patients whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 - 20 weeks) postoperatively
Definition:
Denominator Identification Period - The twelve month period in which eligible patients have a procedure. This allows for enough time for a follow-up assessment to occur during the performance period. The denominator identification period includes dates of procedure (1/1/2018 to 12/31/2018).
Measure Assessment Period (Performance Period) - The period of time following the procedure date that is in which a postoperative VAS pain scale score is obtained.
Preoperative Assessment VAS Pain - A preoperative VAS pain scale score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained via a telephone screening or more than three months before the procedure will not be used for measure calculation.
Postoperative Assessment VAS Pain - A postoperative VAS pain scale score can be obtained from the patient at three months (6 - 20 weeks) after the date of procedure. Assessment scores obtained via a telephone screening or prior to six weeks and after 20 weeks postoperatively will not be used for measure calculation.
Visual Analog Scale (VAS) - A visual analog scale is a continuous line indicating the continuum between two states of being. A copy of the tool can be obtained below or at the following link visual analog scale tool
NUMERATOR NOTE: In the event that a patient’s pain is measured by the Visual Analog Scale (VAS) within three months preoperatively OR at three months (6 to 20 weeks) postoperatively, but not for both the preoperative and postoperative pain measurements, then submit Performance Not Met G9943. In the event that a patient’s pain measurement status is unknown OR was obtained via a telephone screening OR was measured by the Visual Analog Scale (VAS) greater than three months preoperatively OR more than three months ( 6 to 20 weeks) postoperatively OR was measured using a different patient reported pain assessment tool for either the preoperative or postoperative pain measurement, then submit Performance Not Met G9943.
Numerator Options:
Performance Met: Back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 - 20 weeks) postoperatively (G9941)
OR
Performance Not Met: Back pain was not measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 - 20 weeks) postoperatively (G9943)
SUBMISSION CRITERIA 2: AVERAGE CHANGE (PREOPERATIVE TO THREE MONTHS (6 - 20 WEEKS) POSTOPERATIVE) IN BACK PAIN FOR ALL ELIGIBLE PATIENTS 18 YEARS OF AGE OR OLDER AS OF JANUARY 1 OF THE DENOMINATOR IDENTIFICATION PERIOD WHO HAD A LUMBAR DISCECTOMY/LAMINOTOMY PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD AND WHOSE BACK PAIN WAS MEASURED BY THE VISUAL ANALOG SCALE (VAS) WITHIN THREE MONTHS PREOPERATIVELY AND AT THREE MONTHS (6 - 20 WEEKS) POSTOPERATIVELY
Denominator (Submission Criteria 2)
Patients 18 years of age or older as of January 1 of the denominator identification period who had a lumbar discectomy/laminotomy procedure performed during the denominator identification period and whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 - 20 weeks) postoperatively
Definition:
Denominator Identification Period - The twelve month period in which eligible patients have a procedure. This allows for enough time for a follow-up assessment to occur during the performance period. The denominator identification period includes dates of procedure 1/1/2018 to 12/31/2018.
Measure Assessment Period (Performance Period) - The period of time following the procedure date that is in which a postoperative VAS pain scale score is obtained.
Minimum Process of Care Threshold Requirement - Eligible clinician must have at least 50% of all eligible patients receiving lumbar discectomy/laminotomy procedure that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 3 months (6 - 20 weeks) postoperatively. An eligible clinician must submit 100% of the population identified within the Performance Met Criteria for Submission Criteria One of this measure in order to calculate the average rate of change for Submission Criteria Two of this measure.
Preoperative Assessment VAS Pain - A preoperative VAS pain scale score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained via a telephone screening or more than three months before the procedure will not be used for measure calculation.
Postoperative Assessment VAS Pain - A postoperative VAS pain scale score can be obtained from the patient three months (6 - 20 weeks) after the date of procedure. Assessment scores obtained via a telephone screening or prior to six weeks and after 20 weeks postoperatively will not be used for measure calculation.
Visual Analog Scale (VAS) - A visual analog scale is a continuous line indicating the continuum between two states of being. A copy of the tool can be obtained below or at the following link visual analog scale tool
Denominator Criteria (Eligible Cases) 2:
Minimum Threshold Requirement: Eligible clinician has at least 50% of all eligible patients receiving lumbar discectomy/laminotomy procedure that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 3 months (6 - 20 weeks) postoperatively
AND
Back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 20 weeks) postoperatively: G9941
Numerator (Submission Criteria 2)
The average change (preoperative to three months (6 - 20 weeks) postoperative) in back pain for all eligible patients