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 within two days of the date of the identified deficiencies.
This measure is to be submitted each denominator eligible visit for patients seen during the 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.
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.
All visits for patients aged 18 years and older
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):
Patients aged ≥ 18 years on date of encounter
Patient encounter during the performance period (CPT): 92540, 92542, 92546, 92548, 92605, 92607, 92610, 92611, 92612, 92614, 92616, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98940, 98941, 98942, 98943*, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, and 99350
Visits where patient has a documented current functional outcome assessment using a standardized tool AND a documented care plan based on the identified functional outcome deficiencies within two days of the assessment.
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), EAT-10: A Swallowing Screening Tool, Health Partners Hearing Assessment, Tinneti Performance Oriented Mobility Assessment (POMA), and Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF).
NOTE: A functional outcome assessment is multi-dimensional and quantifies pain, musculoskeletal/neuromusculoskeletal, or speech and language 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.
Table 1. Definitions for Magnitude of Effects, Based on Mean Between-Group Differences
>10-20 points on a 0- to 100-point VAS or the equivalent
>20 points on a 0- to 100-point VAS or the equivalent
>10-20 points on the ODI
>20 points on the ODI
Pain or Function
ODI = Oswestry Disability Index; RDQ = Roland Morris Disability Questionnaire; SMD = standardized mean difference; VAS = visual analogue scale.
Chou R, Devo R, Friedly J, Skelly A, Hashimoto R,Weimer M ............................................ & Brodt ED. (2017). Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med, 166:493- 505.
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 at a qualifying encounter within the previous 30 days.
Functional Outcome Deficiencies – Impairment or loss of function related to musculoskeletal/neuromusculoskeletal capacity, including 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
Impairment or loss of function related to speech and language capacity, including but not limited to: swallowing or hearing and/or balance disorders.
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 participate in administration of the functional outcome assessment(s)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.
The follow-up plan must still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.
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 submission is only required at each qualifying encounter 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 is documented within two days of the functional outcome assessment (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 is documented within two days of the functional outcome assessment (G8942)
Denominator Exception: Functional outcome assessment NOT documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized 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 within two days of assessment, reason not given (G8543)
Standardized outcome assessments, questionnaires or tools are a vital part of evidence-based practice. Despite the recognition of the importance of outcomes assessments, questionnaires and tools, recent evidence suggests their use in clinical practice is limited. Utilization of the appropriate outcomes assessment, questionnaires, and tools enhances clinical practice by (1) identifying and quantifying body function and structure limitations, (2) formulating evaluation, diagnosis, and prognosis, (3) forming the plan of care, (4) assisting in evaluating the patient progress towards the goals and validating the benefits of treatment, (5) improving communication between client, clinician, and third party payer, (6) assisting to improve the documentation of care provided (Lesher, et al., 2016; Potter, et al., 2011; Schenk, et al. 2016).
“The use of standardized tests and measures early in an episode of care establishes the baseline status of the patient/client, providing a means to quantify change in the patient's/client's functioning. Outcome measures, along with other standardized tests and measures used throughout the episode of care, as part of periodic reexamination, provide information about whether predicted outcomes are being realized” (American Physical Therapy Association (APTA, 2016).
“Consistent assessment of functional status and capacity, as well as health domains that may contribute to impaired function, can help patients and providers make treatment decisions that align with the patient's values, enhance preprocedure or posthospitalization planning, and prevent use of interventions whose risks could well outweigh their benefits” (High,et al., 2019).
Early in the intervention process, occupational therapists should select outcomes that are valid, reliable, sensitive to change; congruent with client goals and based on their actual or purported ability to predict future outcomes. Outcomes are applied to measure progress and adjust goals and interventions. Results are used to make decisions about future direction of intervention (American Occupational Therapy Association (AOTA), 2014).
“Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggests overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement” (MacDermid et al., 2013).
Barriers to use of classification systems and outcome measures were lack of knowledge, too limiting, and time. Classification systems are being used for decision-making in physical therapy practice for patients with lower back pain (LBP). Lack of knowledge and training seems to be the main barrier to the use of classification systems in practice (Davies et al., 2014). Lesher, et al. (2016) noted that Occupational Therapists who use assessment tools may not have understood the tools design or intent leading to over interpretation, under interpretation, or misuse of the tool.
Treatment for musculoskeletal disorders and associated lost wages is on the increase in the U.S. One in every 2 Americans have a musculoskeletal disorder leading to an estimated cost of $213 billion for treatment, care, and lost wages (Bone and Joint Initiative, USA, 2016). Hoy, et al (2014) noted in the Global Burden of Disease Study, musculoskeletal disorders accounted for 6.8% of the total disability –adjusted life years (DALYs).
Of the musculoskeletal disorders, arthritis was noted to be the most common cause of disability with an estimated 51.8 million people experiencing some level of disability from arthritis (Bone and Joint Initiative, USA, 2016). Osteoarthritis of the upper limbs produces higher disability scores and earlier episodes of disability; while osteoarthritis of the knees, hips, and spine worsens with age and causes progressive disability (Montero, et al., 2016). The total cost of treating osteoarthritis is $580.9 billion, an increase of 13 percent since 2000, with an estimated 25 million people losing an average of 11.4 days of work for a total of 290.8 million lost work days (Bone and Joint Initiative, USA, 2016).
While arthritis is considered the most common cause of disability, there are several other musculoskeletal disorders that are prevalent. The U.S. Bureau of Labor Statistics (2015) reported that musculoskeletal disorders had the highest incidence of injury, 31% of cases, which accounted for more than four thousand lost work days, with sprains, strains, and tears being the most commonly reported. Of those injuries, the most commonly affected was the upper extremities, with hands and shoulder injuries accounting for the majority of missed days (U.S. Bureau of Labor Statistics, 2015).
Also, Marik, et al. (2016) noted that half of the population will experience shoulder pain leading to decreased strength and restricted range of motion (ROM) impacting quality of life and limiting involvement in meaningful occupational activities. In addition, Blanchette, et al. (2016) reported that low back pain is one of the leading causes of disability worldwide, one of the most common reasons patients seek medical care, most common occupational disorder, and major cause of lost work days.
“Balance is a complex phenomenon that entails the interaction of multiple body systems to accomplish the basic task of remaining upright. There is a strong correlation between sitting balance and level of selfcare functioning” (Franc, 2020). For hearing, “…data suggest that people wait on average 7–10 yr after noticing hearing problems before seeking help (Davis et al, 2007). One potential reason for the delay in uptake of hearing health care is that the onset of age-related hearing loss is very gradual, and thus individuals may be unaware of the extent of their impairment. As a result, they do not perceive a need for help (Fischer et al, 2011; Smith et al, 2011; Contrera et al, 2016). As noted by Smith et al (2011), population screening can give individuals who are unaware of a health problem an earlier awareness of that problem” (Saunders, 2019). “Swallowing impairment, or dysphagia, is a known complication of cardiovascular surgical procedures that is reported in up to 70% of patients (Daly et al., 2016). Postoperative dysphagia is associated with delayed resumption of oral intake (Barker et al., 2009), increased likelihood of reintubation (Skoretz et al., 2014), pneumonia (Miles et al., 2018), prolonged hospital stay (Barker et al., 2009), increased cost of care (Kozlow et al., 2003) and mortality (Bicer et al., 2005; Ferraris et al., 2001)…Early and accurate detection of dysphagia is therefore critical to allow timely interventions that optimise patient care (O’Horo et al., 2015)” (York, 2020).
Clinical Recommendation Statements
As a category, functional outcome assessments of everyday tasks are very suitable for evaluating treatment of dysfunctions of the neuromusculoskeletal system. Many questionnaires could be used; choice should depend upon the validity, reliability, responsiveness, and practicality demonstrated in the scientific literature. Functional questionnaires seek to directly quantify symptoms, function and behavior, rather than draw inferences from relevant physiological tests. Clinicians contemplating the use of functional instruments should be aware of differences between questionnaires and choose the most appropriate assessment tool for the specific purpose (Haldeman et al., 2005) (Evidence Class: I, II, III, Consensus Level: 1). Lesher, et al. (2017) and Wales, et al. (2017) found that functional assessments can be descriptive, evaluative, discriminative and/or predictive, and should be tested and validated in the population being tested. The tool should be selected based on purpose of the assessment and type of injury sustained (Lesher, et al, 2017; and Wales, et al., 2016). Utilization of validated pain and function scales help to differentiate treatment approaches in order to improve the patient's ability to function (ICSI, 2012).
Clinicians should use validated functional outcome assessment tools, such as the Disabilities of the Arm, Shoulder and Hand (DASH), the American Shoulder and Elbow Surgeons shoulder scale (ASES), or the Shoulder Pain and Disability Index (SPPADI). These should be utilized before and after interventions intended to alleviate the impairments of body function and structure, activity limitations, and participation restrictions associated with adhesive capsulitis (Kelley et al., 2013) (Guideline). Clinicians should use validated self-report questionnaires, such as the Oswestry Disability Index and the Roland-Morris Disability Questionnaire. These tools are useful for identifying a patient’s baseline status relative to pain, function, and disability and for monitoring a change in a patient’s status throughout the course of treatment (Delitto et al., 2012) (Guideline). Clinicians should use validated self-report questionnaires for patients with neck pain, to identify a patient’s baseline status and to monitor changes relative to pain, function, disability, and psychosocial functioning (Blanpied et al, 2017) (Guideline).
Tracking the outcomes of an implementation program is critical to evaluating its benefit to patients (Kramer et al., 2013). Understanding the clinical course of a condition can help assessment of individual patient outcomes by providing a meaningful point of reference with which to compare an individual patient’s progress (Leaver et al., 2013). The Council on Chiropractic Education (2012) recommended keeping appropriate records of the patient's evaluation and case management needs to aptly respond to changes in patient status, or failure of the patient to respond to care. The Institute of Medicine’s (2012) Living Well with Chronic Illness: A Call for Public Health Action stated the surveillance systems need to be improved to assess health-related quality of life and functional status of patients. The American Physical Therapy Association recommends that clinicians should utilize easily reproducible activity limitation and participation restriction measures associated with the patient’s neck pain to assess the changes in the patient’s level of function over the episode of care (Blanpied et al, 2017) (Guideline).
The American College of Physicians 2017 guidelines for noninvasive treatment of acute, subacute, and chronic low back pain noted that the clinician should utilize non-pharmacologic interventions, such as exercise, spinal manipulation, heat, psychological therapies, etc., prior to pharmacologic interventions. Patients who received non-pharmacologic interventions demonstrated improvement in pain and overall function with fewer harms experience than those patients who received pharmacologic therapies (Chou, R., et al., 2017; & Qaseem, A., et al., 2017).
Outcome assessment scales provide a concise, valid way to track function and improvement in function. Anchored numerical scales are recommended for tracking routine progress, particularly pain interference with important activities. Regional or condition functional outcome scales should be routinely used at baseline and periodic follow-ups. More frequent follow-up is recommended with higher frequency care (Washington State Department of Labor and Industries, 2014).