#471: Average Change in Functional Status Following Lumbar Discectomy/Laminotomy Surgery

Quality ID

471

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 age 18 and older who had 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 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 the 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 functional status 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 functional status assessment using the Oswestry Disability Index (ODI) version 2.1a (patient reported outcome tool) 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 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 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 the functional status 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 functional status was measured by the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool 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 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: M1071

 

Numerator (Submission Criteria 1)

All eligible patients whose functional was measured by using the Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool 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 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 three months (6 to 20 weeks) after the date of procedure. Assessment scores obtained prior to six weeks and after twenty weeks postoperatively will not be used for measure calculation.

Oswestry Disability Index (ODI version 2.1a) Patient Reported Outcome Tool - An Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool 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 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 three months (6 to 20 weeks) postoperatively, but not for both the preoperative and postoperative functional status measurements, then submit Performance Not Met M1049. 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 three months (6 to 20 weeks) postoperatively, then submit Performance Not Met M1049. 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 M1049.

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 three months (6 to 20 weeks) postoperatively (M1048)

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 three months (6 to 20 weeks) postoperatively (M1049)

 

SUBMISSION CRITERIA 2: AVERAGE CHANGE (PREOPERATIVE TO THREE MONTHS (6 TO 20 WEEKS) POSTOPERATIVE) IN FUNCTIONAL STATUS 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 FUNCTIONAL STATUS WAS MEASURED BY THE OSWESTRY DISABILITY INDEX (ODI VERSION 2.1A) PATIENT REPORTED OUTCOME TOOL 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 functional status was measured by the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool 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 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 three months (6 to 20 weeks) after the date of procedure. Assessment scores obtained prior to six weeks and after twenty weeks postoperatively will not be used for measure calculation.

Oswestry Disability Index (ODI version 2.1a) Patient Reported Outcome Tool - An Oswestry Disability Index (ODI version 2.1a) patient reported outcome tool 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 https://eprovide.mapi-trust.org/instruments/oswestry-disability-index

Denominator Criteria (Eligible Cases) 2:

Minimum Threshold Requirement: MIPS eligible clinician has at least 50% of all eligible patients receiving lumbar discectomy/laminotomy procedure whose functional status was measured by the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool within three months preoperatively AND at 3 months (6 to 20 weeks) 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 three months (6 to 20 weeks) postoperatively: M1050

 

Numerator (Submission Criteria 2)

The average change (preoperative to three months (6 to 20 weeks) postoperative) in functional status for all eligible patients

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