2023 MIPS Measure #471: Functional Status After Lumbar Surgery

Measure Description

For patients age 18 and older who had lumbar discectomy/laminectomy or fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * at three months (6 to 20 weeks) postoperatively for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.
* hereafter referred to as ODI

Instructions

This measure is to be submitted each time a patient undergoes a lumbar discectomy/laminectomy or 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.

NOTE: This measure is a target-based measure with two ways to meet the numerator; either a postoperative ODI score that is less than or equal to 22 OR an improvement of 30 points or greater from the preoperative to postoperative score. It is expressed as a proportion or rate. Patients having received a lumbar discectomy/laminectomy or fusion procedure who are not assessed for functional status postoperatively remain in the denominator and are considered as not meeting the target. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures to be utilized for performance calculation.

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 (Submission Criteria 1)

Patients with lumbar discectomy/laminectomy procedure
Patients 18 years of age or older as of January 1 of the denominator identification period who had a lumbar discectomy/laminectomy 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 1/1/2022 to 12/31/2022.

Denominator Criteria (Eligible Cases):

Patients aged ≥ 18 years by January 1 of the Denominator Identification Period

AND

Patient procedure during the denominator identification period (CPT): 63005, 63012, 63017, 63030, 63042 and 63047

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSIONS:

Patient had a lumbar fusion on the same date as the discectomy/laminectomy procedure (CPT): 22533, 22558, 22586, 22612, 22630, 22633

AND NOT

Patient had cancer, acute fracture or infection related to the lumbar spine OR patient had neuromuscular, idiopathic, or congenital lumbar scoliosis: M1041

- 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 (M1041) 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 acute lumbar spine region fracture at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (M1041) 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 (M1041) 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 neuromuscular, idiopathic, or congenital scoliosis – The following codes would be sufficient to define the Denominator Exclusion (M1041) of neuromuscular, idiopathic, or congenital scoliosis- M41.05, M41.06, M41.07, M41.08, M41.45, M41.46, M41.47, M41.115, M41.116, M41.117, M41.125, M41.126, M41.127, M41.25, M41.26, M41.27, Q67.5, Q76.3

Numerator

All eligible patients whose functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively

Definition:

Measure Assessment Period (Performance Period) – The period of time following the procedure date that is in which a postoperative ODI functional status score can be obtained.

Preoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A preoperative ODI functional assessment score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained more than three months before the procedure will not be used for measure calculation. If more than one preoperative ODI was obtained, use the ODI that is the most recent and prior to the procedure.

Postoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A postoperative ODI functional assessment score can be obtained from the patient three months (6 to 20 weeks) after the date of procedure. Assessment scores obtained prior to six weeks and after twenty weeks postoperatively will not be used for measure calculation. If more than one postoperative ODI was obtained during the 6 to 20 weeks following the procedure, use the most recent score obtained during the allowable timeframe. ODI can be obtained below or at the following link https://eprovide.mapi-trust.org/instruments/oswestry-disability-index.

Functional Status Target #1 – A patient who is assessed postoperatively at three months (6 to 20 weeks) after the procedure rates their functional status as less than or equal to 22.

Functional Status Target #2 – A patient who does not meet Functional Status Target #1 is assessed both preoperatively within 3 months prior to the procedure AND postoperatively at three months (6 to 20 weeks) after the procedure AND the improvement is greater than or equal to 30 points.

NUMERATOR NOTE: It is recommended that both a preoperative and postoperative assessment tool be administered to the patient increasing chances that one of the numerator targets will be met. The following situations are those in which the numerator target cannot be reached and Performance Not Met M1049 or G2145 is submitted.

• ODI is not administered postoperatively at three months (6 to 20 weeks)
• Functional status is measured using a different patient reported functional status tool or ODI version
• Postoperative ODI is administered less than 6 weeks or greater than 20 weeks (3 month window)
• Postoperative ODI is greater than 22 and no valid preoperative ODI to measure improvement
• Postoperative ODI is greater than 22 and preoperative ODI (to measure improvement) is administered beyond the three month timeframe prior to and including the date of procedure (e.g. 6 months before procedure)

Numerator Options:

Performance Met: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at three months (6 – 20 weeks) postoperatively was less than or equal to 22 OR Functional status measured by the ODI version 2.1a within three months preoperatively AND at three months (6 - 20 weeks) postoperatively demonstrated an improvement of 30 points or greater (G2144)

OR

Performance Not Met: Functional status was not measured by the Oswestry Disability Index (ODI version 2.1a) at three months (6 - 20 weeks) postoperatively (M1049)

OR

Performance Not Met: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at three months (6 – 20 weeks) postoperatively was greater than 22 AND Functional status measured by the ODI version 2.1a within three months preoperatively AND at three months (6 - 20 weeks) postoperatively demonstrated an improvement of less than 30 points (G2145)

Denominator (Submission Criteria 2)

Patients with lumbar fusion procedure

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 denominator eligible procedure. This allows for enough time for a follow-up assessment to occur during the twelve month performance period. The denominator identification period includes dates of procedure 10/1/2021 to 9/30/2022.

Denominator Criteria (Eligible Cases):

Patients age ≥ 18 years by October 1 of the Denominator Identification Period

AND

Patient procedure during the denominator identification period (CPT): 22533, 22558, 22586, 22612, 22630,22633

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

AND NOT

DENOMINATOR EXCLUSION:

Patient had cancer, acute fracture or infection related to the lumbar spine OR patient had neuromuscular, idiopathic, or congenital lumbar scoliosis: M1041

- 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 (M1041) 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 acute lumbar spine region fracture at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (M1041) 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 (M1041) 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 neuromuscular, idiopathic, or congenital scoliosis – The following codes would be sufficient to define the Denominator Exclusion (M1041) of neuromuscular, idiopathic, or congenital scoliosis: M41.05, M41.06, M41.07, M41.08, M41.45, M41.46, M41.47, M41.115, M41.116, M41.117, M41.125, M41.126, M41.127, M41.25, M41.26, M41.27, Q67.5, Q76.3

Numerator

All eligible patients whose functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively

Definitions:

Measure Assessment Period (Performance Period) – The period of time following the procedure date that a postoperative Oswestry Disability Index (ODI version 2.1a) functional status score can be obtained.

Preoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A preoperative ODI functional assessment score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained more than three months before the procedure will not be used for measure calculation. If more than one preoperative ODI was obtained, use the ODI that is the most recent and prior to the procedure.

Postoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A postoperative ODI functional assessment score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained prior to nine months and after fifteen months postoperatively will not be used for measure calculation. If more than one postoperative ODI was obtained during the 9 to 15 months following the procedure, use the most recent score obtained during the allowable timeframe.

Oswestry Disability Index (ODI version 2.1a) Patient Reported Outcome Tool – An ODI patient reported outcome tool (also known as the Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient's permanent functional disability. The test is considered the ‘gold standard’ of low back functional outcome tools. A copy of the tool can be obtained below or at the following link: https://eprovide.mapi-trust.org/instruments/oswestry-disability-index

Functional Status Target #1 – A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their functional status as less than or equal to 22.

Functional Status Target #2 – A patient who does not meet Functional Status Target #1 is assessed both preoperatively within 3 months prior to the procedure AND postoperatively at one year (9 to 15 months) after the procedure AND the improvement is demonstrated as a decrease in ODI score by greater than or equal to 30 points

NUMERATOR NOTE: It is recommended that both a preoperative and postoperative assessment tool be administered to the patient to increase the chance that one of the numerator targets will be met. The following situations are those in which the numerator target cannot be reached and Performance Not Met M1043 or G2143 is submitted.

• ODI is not administered postoperatively at one year (9 to 15 months)
• Functional status is measured using a different patient reported functional status tool or ODI version
• Postoperative ODI is administered less than 9 months or greater than 15 months (1 year window)
• Postoperative ODI is greater than 22 and no valid preoperative ODI to measure improvement
• Postoperative ODI is greater than 22 and preoperative ODI (to measure improvement) is administered beyond the three month timeframe prior to and including the date of procedure (e.g. 6 months before procedure.)

Numerator Options:

Performance Met: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively was less than or equal to 22 OR Functional status measured by the ODI version 2.1a within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated an improvement of 30 points or greater (G2142)

OR

Performance Not Met: Functional status was not measured by the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively (M1043)

OR

Performance Not Met: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively was greater than 22 AND Functional status measured by the ODI version 2.1a within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated an improvement of less than 30 points (G2143)

Rationale

Mechanical low back functional status (LBP) remains the second most common symptom-related reason for seeing a physician in the United States. Of the US population, 85% will experience an episode of mechanical LBP at some point in their lifetime. For individuals younger than 45 years, LBP represents the most common cause of disability and is generally associated with a work-related injury. It is the third most common reason for disability for individuals older than 45 years. The prevalence of serious mechanical LBP (persisting > 2 wk) is 14%, while the prevalence of true sciatica is approximately 2%.

Overall, spine surgery rates have declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 Medicare beneficiaries. Complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50- 3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17). Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone (Deyo, R. JAMA 2010). The MNCM Spine Surgery Measure development workgroup developed patient reported outcome measures for two populations of patients undergoing different lumbar spine procedures, a more complex procedure (lumbar fusion) and a second procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation. In 2018, the development workgroup reconvened and redesigned the measure construct to a target-based measure and additionally expanded the denominator for this measure to include all lumbar discectomy laminectomy procedures

Rationale for measure construct and calculation change:
The target was derived from a study “Determination of the Oswestry Disability Index score equivalent to a "satisfactory symptom state" in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry-based study”. vanHooff, ML et al Spine J. 2016 Oct;16(10):1221-1230. Patient Acceptable Symptom State (PASS), the highest level of symptom beyond which patients consider themselves well. PASS was compared to post-op ODI to determine an equivalent ODI threshold. ODI score less than or equal to 22 indicates the achievement of an acceptable symptom state and can be used as a criterion for treatment success. [AUC]: 0.89 [sensitivity: 78.3%, specificity: 82.1%] for 1 year follow-up]. The OR benchmark of improvement (30) derived from MNCM data (3 years); the average improvement in points of patients that did achieve the target of less than or equal to 22.

Rationale for the expansion of the denominator and addition of exclusions:
During the original development of this measure, the intent was to have a homogeneous population procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation. This strategy did not translate well from ICD-9 to ICD-10 diagnosis codes and the volume of eligible denominator patients dropped significantly. In 2018, the MNCM development workgroup reconvened for measure construct redesign and adopted a broader denominator population; all applicable discectomy laminectomy procedure codes and not limited by a type of diagnosis (includes all). With this decision, the workgroup decided to adopt the same exclusions for the spine fusion population and added exclusions for spine related cancer, acute fracture or infection, idiopathic or congenital scoliosis.

Clinical Recommendation Statements

Journal of Neurosurgery guidelines indicate that there is no evidence that conflicts with the previous recommendations published in the original version of the guideline. This recommendation is for the use of a reliable, valid and responsive outcomes instrument to assess functional outcome in lumbar spinal fusion patients. It is recommended that when assessing functional outcome in patients treated for low-back pain due to degenerative disease, a reliable, valid, and responsive outcomes instrument, such as the disease-specific Oswestry Disability Index (ODI), be used (Level II evidence).

MEASURE CALCULATION EXAMPLE: