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
This measure is to be submitted each denominator eligible visit for patients seen during the 12 month performance period. The functional outcome assessment is required to be current as defined in the definition section. 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.
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.
All visits for patients aged 18 years and older
Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years on date of encounter
Patient encounter during the performance period (CPT): 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98940, 98941, 98942, 98943, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215
Patients with a documented current functional outcome assessment using a standardized tool AND a documented care plan based on the identified functional outcome deficiencies
Standardized Tool – A tool that has been normed and validated. Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS), Disabilities of the Arm, Shoulder and Hand (DASH), and Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF).
Note: A functional outcome assessment is multi-dimensional and quantifies pain and musculoskeletal/neuromusculoskeletal capacity; therefore, the use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool.
Functional Outcome Assessment – Patient completed questionnaires designed to measure a patient's limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms.
Current (Functional Outcome Assessment) – A patient having a documented functional outcome assessment utilizing a standardized tool and a care plan if indicated within the previous 30 days.
Functional Outcome Deficiencies – Impairment or loss of function related to musculoskeletal/neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches.
Care Plan – A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations, goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient’s health care problems. Care plans may also be known as a treatment plan.
Not Eligible (Denominator Exception) – A patient is not eligible if one or more of the following reasons(s) is documented at the time of the encounter:
• Patient refuses to participate
• Patient unable to complete questionnaire
• Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
Documentation of a current functional outcome assessment must include identification of the standardized tool used.
NUMERATOR NOTE: The intent of this measure is for a functional outcome assessment tool to be utilized at a minimum of every 30 days but reporting is required at each visit due to coding limitations. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality-data code G8942 should be used for reporting purposes.
Performance Met: Functional outcome assessment documented as positive using a standardized tool AND a care plan based, on identified deficiencies on the date of the functional outcome assessment, is documented (G8539)
Performance Met: Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required (G8542)
Performance Met: Functional outcome assessment using a standardized tool is documented within the previous 30 days and a care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented (G8942)
Denominator Exception: Functional outcome assessment NOT documented as being performed, documentation the patient is not eligible for a functional outcome assessment using astandardized tool at the time of the encounter (G8540)
Denominator Exception: Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan at the time of the encounter (G9227)
Performance Not Met: Functional outcome assessment using a standardized tool not documented, reason not given (G8541)
Performance Not Met: Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented, reason not given (G8543)