#469: Average Change in Functional Status Following Lumbar Fusion Surgery

Quality ID

469

NQF

2643

High Priority Measure

Yes

Specifications

Registry

Measure Type

Outcome

Specialty

Neurosurgery Orthopedic Surgery

Measure Description

The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients 18 years of age and older who had a lumbar fusion procedure

 

Instructions

This measure is to be submitted each time a patient undergoes a lumbar fusion 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 functional status 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 fusion procedure) must be submitted.

This measure contains elements of a proportion or rate and a simple average of the change in functional status preoperatively to postoperatively among patients having received a lumbar fusion procedure. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures for performance calculation.

A preoperative and postoperative functional status assessment using the Oswestry Disability Index (ODI) version 2.1a (a patient reported outcome tool) within three months preoperatively AND at one year (9 to 15 months) postoperatively for at least 50% of denominator eligible patients receiving a lumbar fusion procedure is a denominator inclusion criterion to be eligible to submit this performance measure - the average change in preoperative to postoperative functional status (Submission Criteria Two). A MIPS eligible clinician must submit 100% of the population identified with a preoperative and postoperative functional status 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 October 1 of the denominator identification period who had a lumbar fusion procedure performed during the denominator identification period

AND

2) Average change (preoperative to one year postoperative) in functional status for all eligible patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar fusion procedure performed during the denominator identification period and whose functional status was measured by the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively and at one year (9 to 15 months) postoperatively

 

SUBMISSION CRITERIA 1: PATIENTS 18 YEARS OF AGE OR OLDER AS OF OCTOBER 1 OF THE DENOMINATOR IDENTIFICATION PERIOD WHO HAD A LUMBAR FUSION PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD

Denominator (Submission Criteria 1)

Patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar fusion procedure performed during the denominator identification period

Definition:

Denominator Identification Period - The twelve month period in which eligible patients have a denominator eligible procedure. This allows for enough time for a follow-up assessment to occur during the twelve month performance period. The denominator identification period includes dates of procedure 10/1/2017 to 9/30/2018.

Denominator Exclusions:

Patients with a diagnosis of lumbar spine region cancer at the time of the procedure- the following codes would be sufficient to define the Denominator Exclusion (M1041) of lumbar spine region cancer- C41.2, C41.4, C79.51, C79.52, D16.6, D16.8, D48.0, D49.2

Patients with a diagnosis of lumbar spine region fracture at the time of the procedure- the following codes would be sufficient to define the Denominator Exclusion (M1041) of lumbar spine region fracture: M48.44XA, M48.45XA, M48.46XA, M48.47XA, M48.48XA, M48.54XA, M48.55XA, M48.56XA, M48.57XA, M48.58XA, S22.060A, S22.060B, S22.061A, S22.061B, S22.062A, S22.062B, S22.068A, S22.068B, S22.069A, S22.069B, S22.070A, S22.070B, S22.071A, S22.071B, S22.072A, S22.072B, S22.078A, S22.078B, S22.079A, S22.079B, S22.080A, S22.080B, S22.081A, S22.081B, S22.082A, S22.082B, S22.088A, S22.088B, S22.089A, S22.089B, S24.103A, S24.104A, S24.113A, S24.114A, S24.133A, S24.134A, S24.143A, S24.144A, S24.153A, S24.154A, S32.000A, S32.000B, S32.001A, S32.001B, S32.002A, S32.002B, S32.008A, S32.008B, S32.009A, S32.009B, S32.010A, S32.010B, S32.011A, S32.011B, S32.012A, S32.012B, S32.018A, S32.018B, S32.019A, S32.019B, S32.020A, S32.020B, S32.021A, S32.021B, S32.022A, S32.022B, S32.028A, S32.028B, S32.029A, S32.029B, S32.030A, S32.030B, S32.031A, S32.031B, S32.032A, S32.032B, S32.038A, S32.038B, S32.039A, S32.039B, S32.040A, S32.040B, S32.041A, S32.041B, S32.042A, S32.042B, S32.048A, S32.048B, S32.049A, S32.049B, S32.050A, S32.050B, S32.051A, S32.051B, S32.052A, S32.052B, S32.058A, S32.058B, S32.059A, S32.059B, S32.10XA, S32.10XB, S32.110A, S32.110B, S32.111A, S32.111B, S32.112A, S32.112B, S32.119A, S32.119B, S32.120A, S32.120B, S32.121A, S32.121B, S32.122A, S32.122B, S32.129A, S32.129B, S32.130A, S32.130B, S32.131A, S32.131B, S32.132A, S32.132B, S32.139A, S32.139B, S32.14XA, S32.14XB, S32.15XA, S32.15XB, S32.16XA, S32.16XB, S32.17XA, S32.17XB, S32.19XA, S32.19XB, S32.2XXA, S32.2XXB, S32.9XXA, S32.9XXB, S34.101A, S34.102A, S34.103A, S34.104A, S34.105A, S34.109A, S34.111A, S34.112A, S34.113A, S34.114A, S34.115A, S34.119A, S34.121A, S34.122A, S34.123A, S34.124A, S34.125A, S34.129A, S34.131A, S34.132A, S34.139A, S34.3XXA

Patients with a diagnosis of lumbar spine region infection at the time of the procedure- the following codes would be sufficient to define the Denominator Exclusion (M1041) of lumbar spine region infection: M46.25, M46.26, M46.27, M46.28, M46.35, M46.36, M46.37, M46.38, M46.45, M46.46, M46.47, M46.48, M46.55, M46.56, M46.57, M46.58

Patients with a diagnosis of lumbar idiopathic or congenital scoliosis- the following codes would be sufficient to define the Denominator Exclusion (M1041) of idiopathic or congenital scoliosis: M41.05, M41.06, M41.07, M41.08, M41.115, M41.116, M41.117, M41.125, M41.126, M41.127, M41.25, M41.26, M41.27, Q67.5, Q76.3

Denominator Criteria (Eligible Cases) 1:

Patients aged ≥ 18 years by October 1 of the Denominator Identification Period

AND

Patient procedure during performance period (CPT): 22533, 22534, 22558, 22586, 22612, 22630, 22633

AND NOT

DENOMINATOR EXCLUSION:

Patient had cancer, fracture or infection related to the lumbar spine OR patient had idiopathic or congenital scoliosis: M1041

 

Numerator (Submission Criteria 1)

All eligible patients whose functional status was measured by the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool within three months preoperatively AND at one year (9 to 15 months) postoperatively

Definition:

Denominator Identification Period - The twelve month period in which eligible patients have a denominator eligible procedure. This allows for enough time for a follow-up assessment to occur during the twelve month performance period. The denominator identification period includes dates of procedure 10/1/2017 to 9/30/2018.

Measure Assessment Period (Performance Period) - The period of time following the procedure date that is in which a postoperative Oswestry Disability Index (ODI version 2.1a) functional status score can be obtained.

Preoperative Assessment Oswestry Disability Index (ODI version 2.1a)- A preoperative Oswestry Disability Index (ODI version 2.1a) functional assessment score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained more than three months before the procedure will not be used for measure calculation.

Postoperative Assessment Oswestry Disability Index (ODI version 2.1a)- A postoperative Oswestry Disability Index (ODI version 2.1a) functional assessment score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained prior to nine months and after fifteen months postoperatively will not be used for measure calculation.

Oswestry Disability Index (ODI version 2.1a) Patient Reported Outcome Tool - A Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool (also known as the Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient's permanent functional disability. The test is considered the ‘gold standard’ of low back functional outcome tools. A copy of the tool can be obtained below or at the following link: https://eprovide.mapi-trust.org/instruments/oswestry-disability-index

NUMERATOR NOTE: In the event that a patient’s functional status is measured by the Oswestry Disability Index (ODI version 2.1a) within three months preoperatively OR at one year (9 to 15 months) postoperatively, but not for both the preoperative and postoperative functional status measurements, then submit Performance Not Met M1043. In the event that a patient’s functional measurement status is unknown OR was measured by the Oswestry Disability Index (ODI version 2.1a) greater than three months preoperatively OR more than one year (9 to 15 months) postoperatively, then submit Performance Not Met M1043. In the event that a patient’s functional status is measured using a different patient reported functional status assessment tool or version of the tool for either the preoperative or postoperative functional status assessment measurement, then submit Performance Not Met M1043.

Numerator Options:

Performance Met: Functional status measurement with score was obtained utilizing the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively AND at one year (9 to 15 months) postoperatively (M1042)

OR

Performance Not Met: Functional status measurement with score was not obtained utilizing the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively AND at one year (9 to 15 months) postoperatively (M1043)

 

SUBMISSION CRITERIA 2: AVERAGE CHANGE (PREOPERATIVE TO ONE YEAR POSTOPERATIVE) IN FUNCTIONAL STATUS FOR ALL ELIGIBLE PATIENTS 18 YEARS OF AGE OR OLDER AS OF OCTOBER 1 OF THE DENOMINATOR IDENTIFICATION PERIOD WHO HAD A LUMBAR FUSION PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD AND WHOSE FUNCTIONAL STATUS WAS MEASURED BY THE OSWESTRY DISABILITY INDEX (ODI VERSION 2.1A) PATIENT REPORTED OUTCOME TOOL WITHIN THREE MONTHS PREOPERATIVELY AND AT ONE YEAR (9 TO 15 MONTHS) POSTOPERATIVELY

Denominator (Submission Criteria 2)

Patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar fusion procedure performed during the denominator identification period and whose functional status was measured by the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool within three months preoperatively AND at one year (9 to 15 months) postoperatively

Definition:

Denominator Identification Period - The twelve month period in which eligible patients have a denominator eligible procedure. This allows for enough time for a follow-up assessment to occur during the twelve month performance period. The denominator identification period includes dates of procedure 10/1/2017 to 9/30/2018.

Measure Assessment Period (Performance Period) - The period of time following the procedure date that is in which a postoperative Oswestry Disability Index (ODI version 2.1a) functional status score can be obtained.

Preoperative Assessment Oswestry Disability Index (ODI version 2.1a) - A preoperative Oswestry Disability Index (ODI version 2.1a) functional assessment score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained more than three months before the procedure will not be used for measure calculation.

Postoperative Assessment Oswestry Disability Index (ODI version 2.1a) - A postoperative Oswestry Disability Index (ODI version 2.1a) functional assessment score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained prior to nine months and after fifteen months postoperatively will not be used for measure calculation.

Minimum Process of Care Threshold Requirement – MIPS eligible clinician must have at least 50% of all eligible patients receiving lumbar fusion procedure that have back functional status measured with the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool within 3 months preoperatively AND at 1 year (9 to 15 months) 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.

Oswestry Disability Index (ODI version 2.1a) Patient Reported Outcome Tool - An Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool (also known as the Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient's permanent functional disability. The test is considered the ‘gold standard’ of low back functional outcome tools. A copy of the tool can be obtained below or at the following link: https://eprovide.mapi-trust.org/instruments/oswestry-disability-index

Denominator Criteria (Eligible Cases) 2:

Minimum Process of Care Threshold Requirement: MIPS eligible clinician has at least 50% of all eligible patients receiving lumbar fusion procedure that have a functional status measured with the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool within 3 months preoperatively AND at 1 year (9 to 15 months) postoperatively

AND

Functional status was measured by the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool within three months preoperatively AND at one year (9 to 15 months) postoperatively: M1044

 

Numerator (Submission Criteria 2)

The average change (preoperative to one year (9 to 15 months) postoperative) in functional status for all eligible patients

NUMERATOR NOTE: For the purposes of submitting this measure Data Completeness has been determined in Submission Criteria One. The rate calculated for Submission Criteria Two of this measure is calculated using the subset of patients identified in the Performance Met Numerator Option of Submission Criteria One.

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