Measure Description
The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or 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 pain 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 back pain preoperatively to postoperatively among patients having received a lumbar fusion procedure. The measure intent is that eligible clinicians will submit all denominator eligible procedures for performance calculation.
A preoperative and postoperative pain assessment using the Visual Analog Scale (VAS) 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 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 pain assessment (Performance Met Criteria for Submission Criteria One) of this measure for Submission Criteria Two. It is anticipated that MIPS eligible clinicians who perform the listed procedures as specified in the denominator coding should therefore assess both preoperative and postoperative pain AND therefore may submit this measure.
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 back pain 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 back pain was measured by the Visual Analog Scale (VAS) 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 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 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 (G9945) 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 (G9945) 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 (G9945) 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 (G9945) 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: G9945
Numerator (Submission Criteria 1)
All eligible patients whose back pain was measured by the Visual Analog Scale (VAS) 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 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 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 VAS pain scale score is obtained.
Preoperative Assessment VAS Pain - A preoperative VAS pain scale score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained via a telephone screening or more than three months before the procedure will not be used for measure calculation.
Postoperative Assessment VAS Pain - A postoperative VAS pain scale score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained via a telephone screening or prior to 9 months and after 15 months postoperatively will not be used for measure calculation.
Visual Analog Scale (VAS) - A visual analog scale 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 Visual Analog Scale Tool
NUMERATOR NOTE: In the event that a patient’s pain is measured by the Visual Analog Scale (VAS) within three months preoperatively OR at one year (9 to 15 months) postoperatively, but not for both the preoperative and postoperative pain measurements, then submit Performance Not Met G9946. In the event that a patient’s pain measurement status is unknown OR was obtained via a telephone screening OR was measured by the Visual Analog Scale (VAS) greater than three months preoperatively OR more than one year (9 to 15 months) postoperatively OR was measured using a different patient reported pain assessment tool for either the preoperative or postoperative pain measurement, then submit Performance Not Met G9946.
Numerator Options:
Performance Met: Back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively (G9944)
OR
Performance Not Met: Back pain was not measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively (G9946)
SUBMISSION CRITERIA 2: AVERAGE CHANGE (PREOPERATIVE TO ONE YEAR POSTOPERATIVE) IN BACK PAIN 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 BACK PAIN WAS MEASURED BY THE VISUAL ANALOG SCALE (VAS) 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 back pain was measured by the Visual Analog Scale (VAS) 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 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 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 VAS pain scale score is obtained.
Minimum Process of Care Threshold Requirement - Eligible clinician must have at least 50% of all eligible patients receiving lumbar fusion procedure that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 1 year (9 to 15 months) postoperatively. An 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.
Preoperative Assessment VAS Pain - A preoperative VAS pain scale score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained via a telephone screening or more than three months before the procedure will not be used for measure calculation.
Postoperative Assessment VAS Pain - A postoperative VAS pain scale score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained via a telephone screening or prior to 9 months and after 15 months postoperatively will not be used for measure calculation.
Visual Analog Scale (VAS) - A visual analog scale is a continuous line indicating the continuum between two states of being. A copy of the tool can be obtained at Visual Analog Scale Tool
Denominator Criteria (Eligible Cases) 2:
Minimum Process of Care Threshold Requirement: Eligible clinician has at least 50% of all eligible patients receiving lumbar fusion procedure that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 1 year (9 to 15 months) postoperatively
AND
Back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively: G9944
Numerator (Submission Criteria 2)
The average change (preoperative to one year (9 to 15 months) postoperative) in back pain for all eligible patients