Measure Description
The Patient Activation Measure® (PAM®) is a 10- or 13-item questionnaire that assesses an individual´s knowledge, skills, and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM® performance measure (PAM®- PM) is the change in score on the PAM® from baseline to follow-up measurement.
Instructions
This measure is to be submitted a minimum of once per performance period for patients, without specific disease, seen during the performance period. This measure is intended to reflect the quality of services provided for patients who received a baseline PAM® score and a second PAM® score in a 6 to 12 month period from the baseline PAM® score. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who provided the measure-specific denominator coding.
Unique to this measure is the Minimum Performance Threshold Requirement. This measure-based threshold includes two requirements:
- Clinicians must have collected a follow-up PAM® survey on at least 50% of all eligible patients during the performance period.
- Clinicians must have administered a follow-up PAM® survey to a minimum of 50 unique patients.
Therefore, if the performance rate for Submission Criteria 1 is below 50% and does not include 50 unique patients, the MIPS eligible clinician would not be able to meet the denominator of the Submission Criteria 2 and this measure CANNOT BE SUBMITTED. CMS anticipates the performance rate for Submission Criteria 2 and Submission Criteria 3 will be calculated using 100% of patients that met performance in Submission Criteria 1.
The survey will be available at www.phreesia.com/mips. Clinicians will be able to administer the PAM® on paper, via phone, electronically via email, or through a free web portal provided by Phreesia Inc. The portal will allow users to administer the PAM® survey to patients and record a patient’s responses to the survey questions that were administered using other modalities. These responses will be automatically scored. In addition, clinicians will be able to view reports on patient PAM® responses.
This measure will be calculated with 3 performance rates:
1) Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period.
2) Percentage of patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period.
3) Average change between baseline PAM® score and the second score within 6 to 12 months of a baseline PAM® score.
NOTE: This measure contains 4 submission criteria that are utilized to calculate the 3 performance rates. For accountability reporting in the CMS MIPS program, Submission Criteria 2 will be used for performance.
NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, 95, POS 02, POS 10) 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.
THERE ARE FOUR SUBMISSION CRITERIA FOR THIS MEASURE:
1) All patients aged 14 years and older who had two PAM® scores 6 to 12 months apart AND
2) All patients aged 14 years and older who achieved a net increase in PAM® score of at least 3 points AND
3) All patients aged 14 years and older who achieved a net increase in PAM® score of at least 6 points AND
4) Average change in PAM® score
SUBMISSION CRITERIA 1: ALL PATIENTS WHO HAD TWO PAM® SCORES 6 TO 12 MONTHS APART
DENOMINATOR (SUBMISSION CRITERIA 1):
Patients aged 14 years and older with a qualifying visit at least once during the performance period
Denominator Instructions:
The measure is not disease specific but has been successfully used with a wide variety of chronic conditions, as well as with people with no medical diagnosis.
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 14 years and older on date of encounter
AND
Patient encounters during the performance period (CPT or HCPCS): 99202, 99203, 99204,99205, 99211, 99212, 99213, 99214, 99215, 90834, 90837, 97164, 97165, 97166, 97167, 98966, 98967, 98968, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99424, 99441, 99442, 99443, 99484, 99491, 99492, 99493, 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, G0402, G0438, G0439
AND NOT
DENOMINATOR EXCLUSIONS:
Diagnosis of Dementia (ICD-10-CM): F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F10.27, F10.97, F13.97, F13.27, F18.17, F18.27, F19.97, F19.17, F19.27, G31.0
OR
Diagnosis of Huntington's disease (ICD-10-CM): G10
OR
Diagnosis of Cognitive Impairment or Alzheimer’s disease (ICD-10-CM): A81.00, A81.09, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, G30.0, G30.1, G30.9, G31.01, G31.09, G31.84, G40.909, I67.850, R41.0
NUMERATOR (SUBMISSION CRITERIA 1):
Patients with a Baseline PAM® score and then a second score taken within 12 months of the baseline (but not less than 6 months)
Definitions:
Follow-up – The second PAM® score must occur during the performance period (January 1 through December 31).
Level 4 – Scores on the PAM® survey range from 0-100 that are then converted to Levels ranging from Level 1 to “Level 4”, with “Level 4” being the highest level of activation.
Extreme Straight line Response Sets – PAM® surveys where all responses are either ‘Agree Strongly’ or all responses are ‘Disagree Strongly’.
Numerator Instructions:
The Baseline PAM® score can be captured during the current performance period or the prior performance period, however, the follow-up PAM® score should be captured during the current performance period for the purposes of this measure.
Numerator Options:
Performance Met: Patients who had a baseline PAM® score and a second score within 6 to 12 month of baseline PAM® score (M1345)
OR
Denominator Exception: Patients who are at PAM® Level 4 at baseline or patients who are flagged with extreme straight line response sets on the PAM® (M1343)
OR
Performance Not Met: Patients who did not have a baseline PAM® score and/or a second score within 6 to 12 month of baseline PAM® score (M1344)
AND
SUBMISSION CRITERIA 2: ALL PATIENTS AGED 14 YEARS AND OLDER WHO ACHIEVED A NET INCREASE IN PAM® SCORE OF AT LEAST 3 POINTS
DENOMINATOR (SUBMISSION CRITERIA 2):
Patients aged 14 years and older with Performance Met for Submission Criteria 1 who had a baseline PAM® score and a second score within 6 to 12 month of baseline PAM® score and who were seen for a qualifying visit at least once during the performance period
Definition:
Follow-up – Must occur during the performance period (January 1 through December 31). Denominator Instructions: A positive change would mean the patient is gaining in their ability to manage their health. The measure is not disease specific but has been successfully used with a wide variety of chronic conditions, as well as with people with no medical diagnosis.
DENOMINATOR NOTE: Individual clinicians would need to have two PAM® scores on at least 50% of their eligible population and a minimum of 50 patients with two PAM® scores.
Providers are not penalized for having a large percentage of patients with low activation scores, as those patients have the most room for gains if appropriately supported. Performance is based on the change between the PAM® scores.
*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):
Minimum Process of Care Threshold Requirement: At least 50% of all eligible patients had a PAM® score assessed at baseline and 6 to 12 months of baseline (Performance Rate for Submission Criteria 1)
AND
Minimum Case Threshold Requirement: At least 50 eligible patients had a PAM® score assessed at baseline and 6 to 12 months of baseline (Performance Rate Numerator for Submission Criteria 1: M1345)
AND
Patients aged 14 years and older on date of encounter
AND
All eligible instances when M1345 is submitted for Performance Met (patient received clinical follow-up and PAM® score assessed at 6 to 12 months) in the numerator of Submission Criteria 1
AND
Patient encounters during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 90834, 90837, 97164, 97165, 97166, 97167, 98966, 98967, 98968, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99424, 99441, 99442, 99443, 99484, 99491, 99492, 99493, 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, G0402, G0438, G0439
AND NOT
DENOMINATOR EXCLUSIONS:
Diagnosis of Dementia (ICD-10-CM): F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F10.27, F10.97, F13.97, F13.27, F18.17, F18.27, F19.97, F19.17, F19.27, G31.0
OR
Diagnosis of Huntington's disease (ICD-10-CM): G10
OR
Diagnosis of Cognitive Impairment or Alzheimer’s disease (ICD-10-CM): A81.00, A81.09, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, G30.0, G30.1, G30.9, G31.01, G31.09, G31.84, G40.909, I67.850, R41.0
NUMERATOR (SUBMISSION CRITERIA 2):
Percentage of eligible patients who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period (passing)
Definition:
Patient Activation Measure-Performance Measure – The PAM®-PM, requires that PAM® be measured at two points in time with the second measure occurring within 6 to 12 months from the baseline measure. The difference in PAM® score from time 1 to time 2 is the change score.
Numerator Instructions:
A “passing” score for eligible patients would be to show an average net 3 point PAM® score increase in a 6 to 12 month period. An “excellent” score for eligible patients would be to show an average net 6 point PAM® score increase in a 6 to12 month period. However, a PAM® score of “passing” or “excellent” meets performance for this measure.
If there are multiple PAM® scores available, the most recent PAM® score should be utilized for the follow-up PAM® score, while the Baseline PAM® score should be the earliest PAM® score that falls within the 6 to 12 months prior to the date of the follow-up.
Numerator Options:
Performance Met: Patients who achieved a net increase in PAM® score of at least 3 points in a 6 to 12 month period (passing) (M1347)
OR
Performance Not Met: Patients who did not have a net increase in PAM® score of at least 3 points within 6 to 12 month period (M1349)
AND
SUBMISSION CRITERIA 3: ALL PATIENTS AGED 14 YEARS AND OLDER WHO ACHIEVED A NET INCREASE IN PAM® SCORE OF AT LEAST 6 POINTS
DENOMINATOR (SUBMISSION CRITERIA 3):
Patients aged 14 years and older with Performance Met for Submission Criteria 1 who had a baseline PAM® score and a second score within 6 to 12 month of baseline PAM® score and who were seen for a qualifying visit at least once during the performance period
Denominator Instructions:
A positive change would mean the patient is gaining in their ability to manage their health. The measure is not disease specific but has been successfully used with a wide variety of chronic conditions, as well as with people with no medical diagnosis.
DENOMINATOR NOTE: Individual clinicians would need to have two PAM® scores on at least 50% of their eligible population and a minimum of 50 patients with two PAM® scores.
Providers are not penalized for having a large percentage of patients with low activation scores, as those patients have the most room for gains. Performance is based on the change between the PAM® scores.
*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):
Minimum Process of Care Threshold Requirement: At least 50% of all eligible patients had a PAM® score assessed at baseline and 6 to 12 months of baseline (Performance Rate for Submission Criteria 1)
AND
Minimum Case Threshold Requirement: At least 50 eligible patients had a PAM® score assessed at baseline and 6 to 12 months of baseline (Performance Rate Numerator for Submission Criteria 1: M1345)
AND
Patients aged 14 years and older on date of encounter
AND
All eligible instances when M1345 is submitted for Performance Met (patient received clinical follow-up and PAM® score assessed at 6 to 12 months) in the numerator of Submission Criteria 1
AND
Patient encounters during the performance period (CPT or HCPCS): 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 90834, 90837, 97164, 97165, 97166, 97167, 98966, 98967, 98968, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99401*, 99402*, 99403*, 99424, 99441, 99442, 99443, 99484, 99491, 99492, 99493, 99384*, 99385*, 99386*, 99387*, 99394*, 99395*, 99396*, 99397*, G0402, G0438, G0439
AND NOT
DENOMINATOR EXCLUSIONS:
Diagnosis of Dementia (ICD-10-CM): F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F10.27, F10.97, F13.97, F13.27, F18.17, F18.27, F19.97, F19.17, F19.27, G31.0
OR
Diagnosis of Huntington's disease (ICD-10-CM): G10
OR
Diagnosis of Cognitive Impairment or Alzheimer’s disease (ICD-10-CM): A81.00, A81.09, G20.A1, G20.A2, G20.B1, G20.B2, G20.C, G30.0, G30.1, G30.9, G31.01, G31.09, G31.84, G40.909, I67.850, R41.0
NUMERATOR (SUBMISSION CRITERIA 3):
Percentage of eligible patients who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period (excellent)
Definition:
Patient Activation Measure-Performance Measure – The PAM®-PM, requires that PAM® be measured at two points in time with the second measure occurring within 6 to 12 months from the baseline measure. The difference in PAM® score from time 1 to time 2, or the change score is the PAM®-PM.
Numerator Instructions:
A “passing” score for eligible patients would be to show an average net 3 point PAM® score increase in a 6 to 12 month period. An “excellent” score for eligible patients would be to show an average net 6 point PAM® score increase in a 6 to12 month period. However, a PAM® score of “passing” or “excellent” meets performance for this measure.
If there are multiple PAM® scores available, the most recent PAM® score should be utilized for the follow-up PAM® score, while the baseline PAM® score should be the earliest PAM® score that falls within the 6 to 12 months prior to the date of the follow-up
Numerator Options:
Performance Met: Patients who achieved a net increase in PAM® score of at least 6 points in a 6 to 12 month period (excellent) (M1348)
OR
Performance Not Met: Patients who did not have a net increase in PAM® score of at least 6 points within a 6 to 12 month period (M1346)
AND
SUBMISSION CRITERIA 4: AVERAGE CHANGE IN PAM® SCORE
DENOMINATOR (SUBMISSION CRITERIA 4):
Patients aged 14 years and older with Performance Met for Submission Criteria 1 who had a baseline PAM® score and a second score within 6 to 12 months of the baseline PAM® score and who were seen for a qualifying visit at least once during the performance period
Denominator Criteria (Eligible Cases):
Minimum Process of Care Threshold Requirement: At least 50% of all eligible patients had a PAM® score assessed at baseline and 6 to 12 months of baseline (Performance Rate for Submission Criteria 1)
AND
Minimum Case Threshold Requirement: At least 50 eligible patients had a PAM® score assessed at baseline and 6 to 12 months of baseline (Performance Rate Numerator for Submission Criteria 1: M1345)
NUMERATOR (SUBMISSION CRITERIA 4):
The average change (net difference) for all eligible patients between the baseline PAM® score and the second score taken within 12 months of the baseline (but not less than 6 months)
Definitions:
Patient Activation Measure-Performance Measure – The PAM®-PM, requires that PAM® be measured at two points in time with the second measure occurring within 6 to 12 months of baseline measure. The difference in PAM® scores from time 1 to time 2, or the change score is used to report the PAM®-PM.
Change in PAM® score – The change in PAM® score of eligible patients associated with a specific eligible clinician or group unit (e.g., patients in a primary care provider’s panel or in a clinic), expressed as the difference between the baseline PAM® score and then a second score taken within 12 months of the baseline (but not less than 6 months).
NUMERATOR NOTE: The average change in PAM® scores is calculated as the sum of the change in PAM® scores for eligible patients divided by the total eligible patients in denominator of Submission Criteria 4.
Rationale
The Patient Activation Measure (PAM®) assesses an individual’s ability to manage their own health and health care. The measure is not disease specific; it has been successfully used with a wide variety of chronic conditions, as well as with people with no conditions. The PAM® is predictive of most health outcomes, including such diverse outcomes as how a patient fares after orthopedic surgery; remission of depression over time; the likelihood of hospital re-admission or ambulatory care sensitive (ACS) utilization; the trajectory of a chronic disease over time; and even the likelihood of a new chronic disease diagnosis in the coming year. The PAM® surveys the knowledge, skill, and confidence necessary for self-management on a 0-100-point scale that can be broken down into 4 levels from low activation to high activation. The 13 (or 10) item survey has strong measurement properties and is predictive of most health behaviors and many clinical outcomes. PAM® scores are also predictive of health care costs, with lower scores predictive of higher costs.
The PAM® is in use both in the US and internationally in research (including more than 800 peer-reviewed journal articles) as well as clinical settings. It has been translated into more than 30 languages. Because researchers all over the world use PAM®, we have been able to validate the instrument with people of different racial and ethnic backgrounds, and with people from different socio-economic levels. The measure has been shown to be valid and reliable in different clinical settings and under different payment models.
A performance measure assessing average changes in PAM® scores has been endorsed by CBE (CBE#2483). The Patient Activation Measure-Performance Measure, the PAM®-PM, requires that PAM® be measured at two points in time. The difference in PAM® score from time 1 to time 2, or the change score is the PAM®-PM. This measure, as well as the PAM® survey, is used in a number of federal quality and payment programs.
Clinical Recommendation Statements
While there are a few other measures that seek to assess patient engagement and activation, they do not possess the strong measurement properties of PAM® and do not have the depth of research supporting their validity and reliability. PAM® is the only measure of self-management capability endorsed by CBE to measure performance. While PAM® is built upon a true equal interval scale, as is the case with measures in the natural sciences (e.g. temperature, weight, HbA1c, blood pressure), competing measures of patient engagement utilize ordinal measurement (a lower form of measurement), that lacks the precision and consistency of interval level measurement Because of these strong measurement properties, researchers from all over the world chose to utilize the PAM® when assessing activation or self-management ability in their studies.