Measure Description
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) (©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 by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)
Instructions
This patient reported outcome measure is to be submitted once per treatment episode for all patients with a functional deficit related to the low back region. This is a patient reported outcome measure and its calculation requires submitting of the patient’s FS score, as a minimum, at admission to and again at discharge from an episode of rehabilitation. The admission score is recorded during the first rehabilitation treatment encounter, and the discharge score is recorded at or near the conclusion of the final rehabilitation treatment encounter. It is anticipated that Merit-based Incentive Payment System (MIPS) eligible clinicians providing treatment for functional deficits related to the low back region will submit this measure.
Definitions:
Functional Deficit – Limitation or impairment of physical abilities/function resulting in evaluation and inclusion in a treatment plan of care.
Treatment Episode – A Treatment Episode is defined as beginning with an Admission for a functional low back deficit, progressing to development of a plan of care, including treatment, without interruption of care (for example, a hospitalization or surgical intervention), and ending with Discharge from clinical care by the MIPS eligible clinician. A patient currently under clinical care for a low back functional deficit remains in a single episode of care until the Discharge is conducted and documented by the MIPS eligible clinician.
Admission (Option 1 & 2) – An Admission is the first encounter for a functional deficit involving the low back and includes an evaluation (CPT 97161, 97162, 97163 for physical therapy or 97165, 97166, 97167 for occupational therapy) and development of a plan of care by the MIPS eligible clinician. A patient presenting with a low back impairment, who has had an interruption of a Treatment Episode for the same functional deficit secondary to an appropriate reason like hospitalization or surgical intervention, is a new Admission.
Admission (Option 3 & 4) – An Admission is the first encounter for a functional deficit involving the low back and includes an evaluation (CPT 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 for physician or 98940, 98941, 98942, 98943 for chiropractic care) and development of a plan of care by the MIPS eligible clinician. A patient presenting with a low back impairment, who has had an interruption of a Treatment Episode for the same functional deficit secondary to an appropriate reason like hospitalization or surgical intervention, is a new Admission.
Discharge (Option 1 & 2) – Discharge is accompanied by a re-evaluation CPT 97164 for physical therapy, or 97168 for occupational therapy, or Functional Limitation Submitting Discharge Status G-Code (G8980, G8983, G8986, G8989, G8992 or G8995) identifying the close of a Treatment Episode for the same low back deficit identified at admission and documented by a Discharge report by the MIPS eligible clinician. An interruption in clinical care for an appropriate reason like hospitalization or surgical intervention requires a Discharge from the current Treatment Episode.
Discharge (Option 3 & 4) – Discharge is accompanied by a treatment finalization and evaluation completion M-Code (M1012) for physicians and chiropractors identifying the close of a Treatment Episode for the same low back deficit identified at admission and documented by a Discharge report by the MIPS eligible clinician. An interruption in clinical care for an appropriate reason like hospitalization or surgical intervention requires a Discharge from the current Treatment Episode.
Encounter – A face to face visit between the patient and the provider for the purpose of assessing and/or improving a functional deficit.
Patient Reported – The patient directly provides answers to the FS measure items using standardized, reliable and valid, computerized adaptive testing or paper and pencil methods. If the patient cannot reliably respond independently (e.g. in the presence of cognitive deficits), a suitable proxy may provide answers.
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.
Denominator
All patients 14 years and older with a low back impairment who have initiated rehabilitation treatment and completed the Low Back FS PROM DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.
Option 1 – Physical Therapy Denominator Criteria (Eligible Cases):
All patients aged ≥ 14 years on date of encounter
AND
Patient encounter during the performance period identifying evaluation (CPT): 97161, 97162, 97163
AND
Patient encounter during the performance period identifying discharge (CPT or HCPCS): 97164, G8980, G8983, G8986, G8989, G8992, G8995
AND
Functional deficit affecting the low back region
AND NOT
DENOMINATOR EXCLUSIONS:
Patient refused to participate: G9732
OR
Patient unable to complete the Low Back FS PROM at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available: G9733
OR
Option 2 – Occupational Therapy Denominator Criteria (Eligible Cases):
All patients aged ≥ 14 years on date of encounter
AND
Patient encounter during the performance period identifying evaluation (CPT): 97165, 97166, 97167
AND
Patient encounter during the performance period identifying discharge (CPT or HCPCS): 97168, G8980, G8983, G8986, G8989, G8992, G8995
AND
Functional deficit affecting the low back region
AND NOT
DENOMINATOR EXCLUSIONS:
Patient refused to participate: G9732
OR
Patient unable to complete the Low Back FS PROM at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available: G9733
OR
Option 3 – Physician Denominator Criteria (Eligible Cases)
All patients aged ≥ 14 years on date of encounter
AND
Patient encounter during the performance period identifying evaluation (CPT): 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215
AND
Patient treatment and final evaluation complete: M1012
AND
Functional deficit affecting the low back region
AND NOT
DENOMINATOR EXCLUSIONS:
Patient refused to participate: G9732
OR
Patient unable to complete the Low Back FS PROM at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available: G9733
OR
Option 4 – Chiropractic Care Denominator Criteria (Eligible Cases)
All patients aged ≥ 14 years on date of encounter
AND
Patient encounter during the performance period identifying evaluation (CPT): 98940, 98941, 98942, 98943*
AND
Patient treament and final evaluation complete: M1012
AND
Functional deficit affecting the low back region
AND NOT
DENOMINATOR EXCLUSIONS:
Patient refused to participate: G9732
OR
Patient unable to complete the Low Back FS PROM at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available: G9733
Numerator
Patients who were presented with the Low Back FS PROM at Admission (Intake) and Discharge (Status) for the purpose of calculating the patient’s Risk-Adjusted Functional Status Change Residual Score
Definitions:
Patient’s Functional Status Score – A functional status score is produced when the patient completes the FS measure (either by paper and pencil or computerized adaptive testing administration). The FS score is continuous and linear. Scores range from 0 to 100 with higher scores indicating higher functional abilities. The measure is standardized, and the scores are validated for the measurement of function for this population.
Patient’s Functional Status Change Score – A functional status change score is calculated by subtracting the Patient’s Functional Status Score at Admission from the Patient’s Functional Status Score at Discharge.
Predicted Functional Status Change Score – Functional Status Change Scores for patients are risk adjusted using multiple linear regression methods that include the following independent variables: Patient’s Functional Status Score at Admission, patient age, symptom acuity, surgical history, gender, specific co- morbidities, use of medication for the condition at Intake, exercise history, history of previous treatment for the condition and type of post-surgical status. The Patient’s Functional Status Change Score is the dependent variable. For each patient completing a functional status assessment at admission (intake), the regression model provides a risk-adjusted prediction of functional status change at discharge.
Risk-Adjusted Functional Status Change Residual Score – The difference between the raw non-risk- adjusted Patient’s Functional Status Change Score and the Risk-Adjusted Predicted Functional Status Change Score (raw minus predicted) is the Risk-Adjusted Functional Status Change Residual Score, which is in the same units as the Patient’s Functional Status Score, and should be interpreted as the unit of functional status change different than predicted given the risk-adjustment variables of the patient being treated. As such, the Risk-Adjusted Residual Change Score represents Risk-Adjusted Change corrected for the level of severity of the patient. Risk-Adjusted Residual Change Scores of zero (0) or greater (> 0) should be interpreted as functional status change scores that were predicted or better than predicted given the risk- adjustment variables of the patient, and risk-adjusted residual change scores less than zero (< 0) should be interpreted as functional status change scores that were less than predicted given the risk-adjustment variables of the patient. Aggregated Risk-Adjusted Residual Scores allow meaningful comparisons amongst clinicians or clinics.
Not Appropriate (Denominator Exception) – Prior to conclusion of Plan of Care, intervention was interrupted or discontinued for any reason including by the referring physician, the provider, the payer or the patient, and attempts by the provider to complete a follow-up functional status survey near Discharge were unsuccessful.
Numerator Options:
Performance Met: Risk-Adjusted Functional Status Change Residual Score for the low back impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) (G8659)
OR
Performance Met: Risk-Adjusted Functional Status Change Residual Score for the low back impairment successfully calculated and the score was less than zero (< 0) (G8660)
OR
Denominator Exception: Risk-Adjusted Functional Status Change Residual Score for the low back impairment not measured because the patient did not complete the FS Status Survey near discharge, patient Not Appropriate (G8661)
OR
Performance Not Met: Risk-Adjusted Functional Status Change Residual Score for the low back impairment not measured because the patient did not complete the FS Intake Survey on admission and/or follow up FS Status Survey near discharge, reason not given (G8662)