2023 MIPS Measure #155: Falls: Plan of Care

Measure Description

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.

Instructions

This measure is to be submitted a minimum of once per performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure is appropriate for use in all non-acute settings (with the exception of emergency departments and acute care hospitals). 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.

NOTE: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

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 aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient

Denominator Criteria (Eligible Cases):

Patients aged ≥ 65 years on date of encounter

AND

Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year: 1100F

AND

Patient encounter during the performance period (CPT or HCPCS): 92540, 92541, 92542, 92548, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

DENOMINATOR EXCLUSIONS:

Hospice services for patient occurred any time during the measurement period: G9720

Numerator

Patients with a plan of care for falls documented within 12 months

Definitions:

Plan of Care – Must include: balance, strength, and gait training.

Balance, Strength, and Gait Training – Medical record must include: documentation that balance, strength, and gait training/instructions were provided OR referral to an exercise program, which includes at least one of the three components: balance, strength or gait OR referral to physical therapy.

Fall – A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.

Numerator Instructions:

All components do not need to be completed during one patient visit, but should be documented in the medical record as having been performed within the past 12 months.

Numerator Options:

Performance Met: Falls plan of care documented (0518F)

OR

Denominator Exception: Patient not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair (0518F with 1P)

OR

Performance Not Met: Falls plan of care not documented, reason not otherwise specified (0518F with 8P)

Rationale

Interventions to prevent future falls should be documented for the patient with 2 or more falls or injurious falls.

Clinical Recommendation Statements

The USPSTF recommends exercise or physical therapy to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.

Grade: B Recommendation.

The AGS 2010 Clinical Practice Guidelines Recommend:

Multifactorial/Multicomponent Interventions to Address Identified Risk(s) and Prevent Falls

1. A strategy to reduce the risk of falls should include multifactorial assessment of known fall risk factors and management of the risk factors identified. [A]
2. The components most commonly included in efficacious interventions were:
   1. Adaptation or modification of home environment [A]
   2. Withdrawal or minimization of psychoactive medications [B]
   3. Withdrawal or minimization of other medications [C]
   4. Management of postural hypotension [C]
   5. Management of foot problems and footwear [C]
   6. Exercise, particularly balance, strength, and gait training [A]
3. All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered, but not as sole components of the program. [A]
4. Multifactorial/multicomponent intervention should include an education component complementing and addressing issues specific to the intervention being provided, tailored to individual cognitive function and language. [C]
5. The health professional or team conducting the fall risk assessment should directly implement the interventions or should assure that the interventions are carried out by other qualified healthcare professionals. [A]