MIPS Measures Relevant to Orthopedic Surgery

  1. Quality - 45% of total score:  Report 6 measures, including one Outcome or other High Priority measure for 12 months on at least 70% of eligible encounters to possibly earn more than 3 points on a measure. Note: Small practices (less than 16 in the practice) can earn 3 points on a measure if at least 1 eligible case is reported.  Suggestions for your specialty include, but are not limited to, the following:   
    ID:

    021
    NQF:

    0268
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #021: Perioperative Care: Selection of Prophylactic Antibiotic – First OR Second-Generation Cephalosporin

    Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second-generation cephalosporin prophylactic antibiotic who had an order for a first OR second-generation cephalosporin for antimicrobial prophylaxis

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Neurosurgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Vascular Surgery
    ID:

    023
    NQF:

    0239
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #023: Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)

    Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin (LMWH), Low- Dose Unfractionated Heparin (LDUH), adjusted-dose warfarin, fondaparinux or mechanical prophylaxis to be given within 24 hours prior to incision time or within 24 hours after surgery end time

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Neurosurgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    024
    NQF:

    0045
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #024: Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women Aged 50 Years and Older

    Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient’s on-going care, that a fracture occurred and that the patient was or should be considered for osteoporosis treatment or testing. This measure is submitted by the physician who treats the fracture and who therefore is held accountable for the communication

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Internal Medicine
    • Orthopedic Surgery
    • Preventive Medicine
    • Rheumatology
    ID:

    047
    NQF:

    0326
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #047: Advance Care Plan

    Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Internal Medicine
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    128
    NQF:

    0421
    eMeasure ID:

    CMS69v8
    High Priority:

    No

    2020 MIPS Measure #128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter
    Normal Parameters: Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

    Measure Type
    • Process
    Specifications
    Specialty
    • Cardiology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Urology
    • Vascular Surgery
    ID:

    130
    NQF:

    0419e
    eMeasure ID:

    CMS68v9
    High Priority:

    Yes

    2020 MIPS Measure #130: Documentation of Current Medications in the Medical Record

    Percentage of visits for patients aged 18 years and older for which the MIPS eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Geriatrics
    • Hospitalists
    • Infectious Disease
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Neurosurgery
    • Nutrition/Dietician
    • Obstetrics/Gynecology
    • Oncology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:

    134
    NQF:

    0418
    eMeasure ID:

    CMS2v9
    High Priority:

    No

    2020 MIPS Measure #134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

    Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Clinical Social Work
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Orthopedic Surgery
    • Pediatrics
    • Physical Therapy/Occupational Therapy
    • Preventive Medicine
    ID:

    154
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #154: Falls: Risk Assessment

    Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    155
    NQF:

    0101
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #155: Falls: Plan of Care

    Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Podiatry
    • Preventive Medicine
    • Skilled Nursing Facility
    ID:

    178
    NQF:
    eMeasure ID:
    High Priority:

    No

    2020 MIPS Measure #178: Rheumatoid Arthritis (RA): Functional Status Assessment

    Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) for whom a functional status assessment was performed at least once within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    • Rheumatology
    ID:

    180
    NQF:
    eMeasure ID:
    High Priority:

    No

    2020 MIPS Measure #180: Rheumatoid Arthritis (RA): Glucocorticoid Management

    Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have been assessed for glucocorticoid use and, for those on prolonged doses of prednisone >5 mg daily (or equivalent) with improvement or no change in disease activity, documentation of glucocorticoid management plan within 12 months

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    • Rheumatology
    ID:

    182
    NQF:

    2624
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #182: Functional Outcome Assessment

    Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Chiropractic Medicine
    • Family Medicine
    • Nephrology
    • Orthopedic Surgery
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Preventive Medicine
    • Speech/Language Pathology
    ID:

    217
    NQF:

    0422
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #217: Functional Status Change for Patients with Knee Impairments

    A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
    ID:

    218
    NQF:

    0423
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #218: Functional Status Change for Patients with Hip Impairments

    A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
    ID:

    219
    NQF:

    0424
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments

    A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the Foot/Ankle FS patient- reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
    ID:

    220
    NQF:

    0425
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #220: Functional Status Change for Patients with Low Back Impairments

    A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
    ID:

    221
    NQF:

    0426
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #221: Functional Status Change for Patients with Shoulder Impairments

    A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
    ID:

    222
    NQF:

    0427
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments

    A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist, or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
    ID:

    226
    NQF:

    0028
    eMeasure ID:

    CMS138v8
    High Priority:

    No

    2020 MIPS Measure #226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Audiology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Neurosurgery
    • Obstetrics/Gynecology
    • Oncology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Physical Therapy/Occupational Therapy
    • Plastic Surgery
    • Podiatry
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Speech/Language Pathology
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:

    317
    NQF:
    eMeasure ID:

    CMS22v8
    High Priority:

    No

    2020 MIPS Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

    Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Emergency Medicine
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Nephrology
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Plastic Surgery
    • Preventive Medicine
    • Rheumatology
    • Skilled Nursing Facility
    • Thoracic Surgery
    • Urgent Care
    • Urology
    • Vascular Surgery
    ID:

    318
    NQF:

    0101
    eMeasure ID:

    CMS139v8
    High Priority:

    Yes

    2020 MIPS Measure #318: Falls: Screening for Future Fall Risk

    Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period

    Measure Type
    • Process
    Specifications
    Specialty
    • Audiology
    • Family Medicine
    • Internal Medicine
    • Nephrology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Therapy/Occupational Therapy
    • Podiatry
    ID:

    350
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #350: Total Knee Replacement: Shared Decision-Making: Trial of Conservative (Non-surgical) Therapy

    Percentage of patients regardless of age undergoing a total knee replacement with documented shared decision-making with discussion of conservative (non-surgical) therapy (e.g., non-steroidal anti-inflammatory drug (NSAIDs), analgesics, weight loss, exercise, injections) prior to the procedure

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    351
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #351: Total Knee Replacement: Venous Thromboembolic and Cardiovascular Risk Evaluation

    Percentage of patients regardless of age undergoing a total knee replacement who are evaluated for the presence or absence of venous thromboembolic and cardiovascular risk factors within 30 days prior to the procedure (e.g. history of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), Myocardial Infarction (MI), Arrhythmia and Stroke)

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    358
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #358: Patient-Centered Surgical Risk Assessment and Communication

    Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

    Measure Type
    • Process
    Specifications
    Specialty
    • General Surgery
    • Orthopedic Surgery
    • Otolaryngology
    • Plastic Surgery
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    374
    NQF:
    eMeasure ID:

    CMS50v8
    High Priority:

    Yes

    2020 MIPS Measure #374: Closing the Referral Loop: Receipt of Specialist Report

    Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Dermatology
    • Endocrinology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Interventional Radiology
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Ophthalmology
    • Orthopedic Surgery
    • Otolaryngology
    • Physical Medicine
    • Preventive Medicine
    • Pulmonology
    • Rheumatology
    • Thoracic Surgery
    • Urology
    • Vascular Surgery
    ID:

    375
    NQF:
    eMeasure ID:

    CMS66v8
    High Priority:

    Yes

    2020 MIPS Measure #375: Functional Status Assessment for Total Knee Replacement

    Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    376
    NQF:
    eMeasure ID:

    CMS56v8
    High Priority:

    Yes

    2020 MIPS Measure #376: Functional Status Assessment for Total Hip Replacement

    Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

    Measure Type
    • Process
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    402
    NQF:

    2803
    eMeasure ID:
    High Priority:

    No

    2020 MIPS Measure #402: Tobacco Use and Help with Quitting Among Adolescents

    The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

    Measure Type
    • Process
    Specifications
    Specialty
    • Allergy/Immunology
    • Cardiology
    • Clinical Social Work
    • Dermatology
    • Family Medicine
    • Gastroenterology
    • General Surgery
    • Internal Medicine
    • Mental/Behavioral Health
    • Neurology
    • Obstetrics/Gynecology
    • Oncology
    • Orthopedic Surgery
    • Otolaryngology
    • Pediatrics
    • Physical Medicine
    • Preventive Medicine
    • Rheumatology
    • Thoracic Surgery
    • Urgent Care
    • Vascular Surgery
    ID:

    408
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #408: Opioid Therapy Follow-up Evaluation

    All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    412
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #412: Documentation of Signed Opioid Treatment Agreement

    All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    414
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #414: Evaluation or Interview for Risk of Opioid Misuse

    All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

    Measure Type
    • Process
    Specifications
    Specialty
    • Family Medicine
    • Geriatrics
    • Internal Medicine
    • Neurology
    • Orthopedic Surgery
    • Physical Medicine
    ID:

    418
    NQF:

    0053
    eMeasure ID:
    High Priority:

    No

    2020 MIPS Measure #418: Osteoporosis Management in Women Who Had a Fracture

    The percentage of women age 50-85 who suffered a fracture in the six months prior to the performance period through June 30 of the performance period and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture

    Measure Type
    • Process
    Specifications
    Specialty
    • Endocrinology
    • Family Medicine
    • Internal Medicine
    • Obstetrics/Gynecology
    • Orthopedic Surgery
    ID:

    459
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #459: Back Pain After Lumbar Discectomy/Laminectomy

    For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    460
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #460: Back Pain After Lumbar Fusion

    For patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively
    * hereafter referred to as VAS Pain

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    461
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #461: Leg Pain After Lumbar Discectomy/ Laminectomy

    For patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS Pain scale at three months (6 to 20 weeks) postoperatively

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    469
    NQF:

    2643
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #469: Functional Status After Lumbar Fusion

    For patients 18 years of age and older who had a lumbar fusion procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a)* at one year (9 to 15 months) postoperatively

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    470
    NQF:

    2653
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #470: Functional Status After Primary Total Knee Replacement

    For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) at one year (9 to 15 months) postoperatively

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Orthopedic Surgery
    ID:

    471
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #471: Functional Status After Lumbar Discectomy/Laminectomy

    For patients age 18 and older who had lumbar discectomy/laminectomy procedure, functional status is rated by the patient as less than or equal to 22 OR a change of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    473
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #473: Leg Pain After Lumbar Fusion

    For patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Neurosurgery
    • Orthopedic Surgery
    ID:

    478
    NQF:
    eMeasure ID:
    High Priority:

    Yes

    2020 MIPS Measure #478: Functional Status Change for Patients with Neck Impairments

    This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14+ with neck impairments. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality

    Measure Type
    • Outcome
    Specifications
    Specialty
    • Chiropractic Medicine
    • Orthopedic Surgery
    • Physical Therapy/Occupational Therapy
     
  2. PI: Promoting Interoperability - 25% of total score: For a minimum of 90 days, report all required measures. EHR technology certified to the 2015 Edition certification must be in place by October 3, 2020. There are exclusions available for most of the required measures. Please check your QPP Participation Status to see if you are automatically exempt from PI. If you are exempt, the 25% will be re-weighted to the Quality performance category making it 70% of your score.
  3. IA: Improvement Activities - 15% of total score:  Attest that you completed up to 2 high-weighted activities or 4 medium-weighted activities for a minimum of 90 days. Groups with 15 or fewer participants or if you are in a rural or health professional shortage area, attest that you completed 1 high-weighted or 2 medium-weighted activities for a minimum of 90 days.  There are over 100 possible activities to choose from. The following are suggestions only:

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