High Priority MeasureYes
SpecialtyChiropractic Medicine Orthopedic Surgery Physical Therapy/Occupational Therapy
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)
This patient-reported outcome measure is to be submitted once per Treatment Episode for all patients with a functional deficit related to the shoulder. This is a patient-reported outcome measure and its calculation requires submitting of the patient’s FS PROM score, as a minimum, at the start (Initial Evaluation or Intake) and again at the conclusion (Discharge) of a Treatment Episode. The Initial Evaluation score is recorded during the first treatment encounter, and the Discharge score is recorded at or near the conclusion of the final treatment encounter. It is anticipated that Merit- based Incentive Payment System (MIPS) eligible clinicians providing treatment for functional shoulder deficits will submit this measure.
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 Initial Evaluation for a functional shoulder deficit, progressing through treatment, without interruption (for example, a hospitalization or surgical intervention), and ending with Discharge, signifying that the treatment has been completed. A patient currently under clinical care for a shoulder functional deficit remains in a single Treatment Episode until the Discharge is conducted and documented by the MIPS eligible clinician.
Initial Evaluation – An Initial Evaluation is the first encounter for a functional deficit involving the shoulder and includes an evaluation (CPT 97161, 97162, 97163, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 98940, 98941, 98942, or 98943), or an Initial Evaluation Status M-code (M1126). A patient presenting with a shoulder impairment, who has had an interruption of a Treatment Episode for the same functional shoulder deficit secondary to an appropriate reason like hospitalization or surgical intervention, is an Initial Evaluation.
Discharge – Discharge is accompanied by a treatment finalization and evaluation completion M-Code (M1013) identifying the close of a Treatment Episode for the same shoulder deficit identified at the Initial Evaluation 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 FS measure items using a standardized, reliable and valid, computerized adaptive testing or short form (paper and pencil) method. 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.
All patients 14 years and older with shoulder impairments who have initiated a Treatment Episode
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.
Denominator Criteria (Eligible Cases):
All patients aged >14 on date of Initial Evaluation
Patient encounter during the performance period identifying evaluation (CPT or M-code): 97161, 97162, 97163, 97165, 97166, 97167, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 98940, 98941, 98942, 98943,* or M1126
With a shoulder impairment and/or diagnosis pertaining to a functional deficit affecting the shoulder: M05.81, M06.01, M08.81, M08.91, M12.51, M12.81, M13.11, M14.81, M14.61, M19.01, M19.11, M19.21, M24.01, M24.11, M24.21, M24.31, M24.41, M24.51, M24.61, M24.81, M25.31, M25.41, M25.51, M25.61, M61.01, M61.02, M62.01, M62.02, M62.11, M62.12, M62.41, M62.42, M62.51, M62.52, M65.22, M65.81, M65.82, M66.21, M66.22, M66.31, M66.32, M70.81, M75.0, M75.1, M75.2, M75.3, M75.4, M75.5, M75.8, M75.9, M79.62, M84.31, M84.32, M94.21, S42.0, S42.1, S42.2, S42.3, S42.9, S43.0, S43.1, S43.2, S43.3, S43.4, S43.5, S43.6, S43.7, S43.8, S43.9, S46.0, S46.1, S46.2, S46.3, S46.8, S46.9, S47.1, S47.2, S47.9, Z96.611, Z96.612, Z96.619
Discharge/discontinuation of the episode of care documented in the medical record (M-code): M1013
Documentation stating patient has a diagnosis of a degenerative neurological condition such as ALS, MS, or Parkinson’s diagnosed at any time before or during the episode of care: M1127
Patient unable to complete the Shoulder FS PROM at Initial Evaluation and/or Discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available: G9735
Patients who were presented with the Shoulder FS PROM at Initial Evaluation (Intake) and at or near Discharge (Status) for the purpose of calculating the patient’s Risk-Adjusted Functional Status Change Residual Score
Patient’s Functional Status Score – A functional status score is produced when the patient completes the functional status patient-reported outcome measure (either by short form or computerized adaptive testing administration). The functional status score is continuous and linear. Scores range from 0 to 100 with higher scores meaning 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 Initial Evaluation 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 Initial Evaluation, 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 For each patient completing a functional status assessment at Initial Evaluation (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 Scores, 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.
Performance Met: Risk-Adjusted Functional Status Change Residual Score for the shoulder impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) (G8663)
Performance Not Met: Risk-Adjusted Functional Status Change Residual Score for the shoulder impairment successfully calculated and the score was less than zero (< 0) (G8664)
Denominator Exception: Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only) (M1128)
Denominator Exception: Ongoing care not indicated, patient discharged after only 1-2 visits due to specific medical events, documented in the medical record that make the treatment episode impossible such as the patient becomes hospitalized or scheduled for surgery (M1129)
Denominator Exception: Ongoing care not indicated, patient self-discharged early and seen only 1-2 visits (e.g., financial or insurance reasons, transportation problems, or reason unknown) (M1130)
Denominator Exception: Patient refused to participate (G9734)
Performance Not Met: Risk-Adjusted Functional Status Change Residual Score for the shoulder impairment not measured because the patient did not complete the Shoulder FS PROM at Initial Evaluation and/or near discharge, reason not given (G8666)