#461: Average Change in Leg Pain following Lumbar Discectomy / Laminotomy

Quality ID

461

High Priority Measure

Yes

Specifications

Registry

Measure Type

Outcome

Specialty

Neurosurgery Orthopedic Surgery

Measure Description

The average change (preoperative to three months postoperative) in leg 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 both 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 a lumbar discectomy/laminotomy procedure) must be submitted.

This measure contains elements of a proportion or rate and a simple average of the change in leg 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 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 to 20 weeks) postoperative) in leg 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/laminectomy procedure performed during the denominator identification period and whose leg pain was measured by the Visual Analog Scale (VAS) within three months preoperatively and at three months (6 to 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 of 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: G9948

 

Numerator (Submission Criteria 1)

All eligible patients whose leg pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 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 1/1/2018 to 12/31/2018.

Measure Assessment Period (Performance Period) - The period of time following the procedure date 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 pre-operatively, 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 to 20 weeks) after the date of the procedure. Assessment scores obtained via a telephone screening or prior to 6 weeks and after 20 weeks postoperatively will not be used for measure calculation.

Visual Analog Scale - 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 G9949. 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 G9949.

Numerator Options:

Performance Met: Leg pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 20 weeks) postoperatively (G9947)

OR

Performance Not Met: Leg pain was not measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 20 weeks) postoperatively (G9949)

 

SUBMISSION CRITERIA 2: AVERAGE CHANGE (PREOPERATIVE TO THREE MONTHS (6 TO 20 WEEKS) POSTOPERATIVE) IN LEG 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/LAMINECTOMY PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD AND WHOSE LEG PAIN WAS MEASURED BY THE VISUAL ANALOG SCALE (VAS) WITHIN THREE MONTHS PREOPERATIVELY AND AT THREE MONTHS (6 TO 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 leg pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 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 – A MIPS eligible clinician must have at least 50% of all eligible patients receiving lumbar discectomy/laminotomy that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 3 months (6 to 20 weeks) postoperatively. A MIPS 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 to 20 weeks) after the date of procedure. Assessment scores obtained via a telephone screening or prior to 6 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 Process of Care Threshold Requirement: A MIPS eligible clinician has at least 50% of all eligible patients receiving lumbar discectomy/laminotomy procedures that have leg pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 3 months (6 to 20 weeks) postoperatively

AND

Leg pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at three months (6 to 20 weeks) postoperatively: G9947

 

Numerator (Submission Criteria 2)

The average change (preoperatively to three months (6 to 20 weeks) postoperative) in leg pain for all eligible patients

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