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QCDR/MIPS

Effortless MIPS Reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for MIPS reporting direct to CMS. OBERD has defined a set of measures that assist in MIPS reporting. For OBERD clients, this data is collected effortlessly in the background as part of the patient-reported workflow. 

QCDR/MIPS

10 reasons why you should choose OBERD for MIPS reporting

OBERD is a Qualified Clinical Data Registry (QCDR) and can be used for MIPS reporting direct to CMS. OBERD has defined a set of measures that assist in MIPS reporting. For OBERD clients, this data is collected effortlessly in the background as part of the patient-reported workflow. 

1. Zero staff involvement, after set-up, for data collection and reporting to CMS
2. EMR independent data collection — no more extra “clicks”!
3. Meet 65% of the CPS with patient-reported outcomes
4. Real-time dashboard to monitor and optimize performance
5. Proactive notification of under-performing providers, to help focus your quality-improvement efforts
6. High compliance to form completion, increasing your opportunity for high CPS
7. CMS audit management on your behalf
8. A single data source to report to: CMS, AJRR, AAOS, and any other registry or organization
9. Benchmarking against over 7 million validated patient outcome forms
10. Research-validated data collection forms (license-paid by OBERD)

OBERD QCDR SUPPORTED MEASURES

All of the measures below qualify for MIPS credit. Those labeled “Non-MIPS” were developed by OBERD QCDR and approved by CMS for use in the 2018 MIPS reporting program.

OBERD allows you to collect and report patient-reported measures, independent of your EMR, to meet 65% of the MIPS Composite Performance Score. After set-up, data collection and reporting requires no staff involvement! We do it all for you, including managing CMS audits.


We Guarantee You’ll Avoid a Negative Adjustment

Institutions using OBERD to collect patient-reported outcomes are off to a good start: they will avoid a negative MIPS adjustment. By using a CMS-certified Qualified Clinical Data Registry (QCDR) to collect PROMs, clients can satisfy the Clinical Practice Improvement Activities (CPIA), worth 15% of the MIPS Composite Performance Score. This “two birds one stone” benefit of patient-reported outcomes collection is a good baseline for OBERD’s MIPS strategy and gives a build-in advantage to clients who seek to collect and report Quality data to CMS using OBERD as well. 

 
  • NON-MIPS MEASURES All measures below were developed by OBERD QCDR and approved by CMS, and qualify for 2019 MIPS Reporting Program credit

     

    OBERD22 Post Stroke Outcome and Follow-Up

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: This measure quantifies the quality of care of stroke patients by means of their change in score on a stroke-related patient reported outcome (PRO) instrument. The patient must have a diagnosis of index ischemic stroke (IS), intracerebral hemorrhage (ICH), or transient ischemic attack (TIA); must have completed the PRO instrument at discharge or within 7 days of the diagnosed event (the “baseline” measurement); and must have completed the same PRO between 90 and 120 days after the baseline (the “follow-up” measurement)

    NUMERATOR: Number of patients counted in the denominator for whom a follow-up score is obtained which and has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Differences (MCID) of the questionnaire in use).

    DENOMINATOR: Number of patients 18 or older, diagnosed with IS, ICH, or TIA, who received a baseline score, and who are eligible for a follow-up score during the measurement period.

    DENOMINATOR EXCLUSIONS: Patients unable or unwilling to provide a follow-up

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcomes

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD23 Health Related Quality of Life: Patient Defined Outcomes

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: The finger dexterity goal of a guitarist is poorly measured by a standard question about difficulty buttoning a coat. The object of this measure is to track changes in the level of difficulty, which patients experience in performing a self-defined activity that is especially meaningful to their own quality of life intervention. The level of difficulty is rated on a 0-10 points scale for the self-defined activity and will be assessed based on comparison between pre-intervention and post-intervention scores.

    NUMERATOR: Number of patients counted in the denominator who are asked to rate, on a scale of 0 to 10, the difficulty of performing the activity both before treatment and after treatment, and whose score has improved by at least 2 units on the 10 point scale.

    DENOMINATOR: Number of patients 18 or older who are being treated for an impairment of the ability to perform a self-selected activity of importance to the patient’s quality of life.

    DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcomes

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD25 Patient Satisfaction: Tracking Satisfaction Improvement with CG-CAHPS

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: This is an outcome measure: it measures actual improvement in patient satisfaction. It uses the same scoring approach, which underlies the statistics which CG-CAHPS reports annually. Each individual form is scored as the percentage of questions for which the EC received the top mark; the two most recent forms for each patient are compared; the percentage of patients whose scores did not go down is reported.

    NUMERATOR: Number of patients whose score did not go down between the last two assessments

    DENOMINATOR: Number of patients who have two or more CG-CAHPS scores

    DENOMINATOR EXCLUSION: None

    MEANINGFUL MEASURE AREA: Patient’s Experience of Care

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD28 Hip Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcomes

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, a follow-up patient-reported hip functional assessment (e.g. Harris Hip Score, HOOS, HOOS-PS, HOOS Jr, Oxford Hip, or equivalent CAT assessment if available) that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up hip score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx in comparison to baseline.

    DENOMINATOR: Number of patients whose follow-up hip score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx in comparison to baseline.

    DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD31 Quality of Life-Mental Health Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Engagement/ Experience

    HIGH PRIORITY: Yes, Outcomes

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a mental component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.

    NUMERATOR: Number of patients whose follow-up QoL Mental Component Score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx in comparison to baseline.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, at least one follow-up QoL assessment completed.

    DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD32 Quality of Life – Physical Health Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes TYPE: Patient Engagement/Experience

    HIGH PRIORITY: Yes, Outcomes

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, a follow-up quality of life (QoL) patient-reported outcomes assessment (VR-12, SF-12, SF-36, PROMIS Global 10 or equivalent Computer Adaptive Test (CAT) assessment if available) which yielded a physical component score that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented. In addition, the AAOS Quality Outcomes Work Group recommends that QoL PROs in the clinical setting can lead to improved care.

    NUMERATOR: Number of patients whose follow-up QoL Physical Component Score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx in comparison to baseline.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, at least one follow-up QoL assessment completed.

    DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD33 Patient Acceptable Symptom State Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes TYPE: Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients 18 years or older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, a follow-up Patient Acceptable Symptoms State (PASS) assessment that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose PASS score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx in comparison to baseline.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, at least one PASS assessment completed.

    DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    OBERD34 Upper Extremity Functional Outcomes

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: No

    DESCRIPTION: Percentage of patients 18 years of age and older who completed a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, a follow-up patient-reported upper extremity functional assessment (e.g. PROMIS Upper Extremity, ASES, ASES – elbow, Oxford Shoulder Score, Oxford Instability Score, Penn Shoulder Score, Boston questionnaire, DASH, Quick DASH, PRWE, or equivalent CAT assessment if available) that showed a statistically significant improvement in comparison to initial assessment or who had already reported a score in which there is no room for statistical improvement. The use of Patient Reported Outcomes (PROs) in clinical research is well documented.

    NUMERATOR: Number of patients whose follow-up upper extremity score has a clinical improvement (improvement meets or exceeds the Minimally Clinically Important Difference (MCID) of the questionnaire in use) during the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx in comparison to baseline.

    DENOMINATOR: Number of patients 18 years and older who have a baseline and, within the CY(calendar year) reporting period of Jan. 1, 20xx – Dec.31, 20xx, at least one follow-up upper extremity assessment completed.

    DENOMINATOR EXCLUSION: Patient who has a max score at baseline.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    CCOME1 Patient-Reported Pain and/or Function Improvement after Total Knee arthroplasty

    QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients aged 18 years or older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary total knee arthroplasty (TKA) surgery. PROMs include any validated measures of knee-related pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

    NUMERATOR: Patients whose knee pain and/or function scores at 9-15 months post-op improved by at least 10% (e.g., 10 points on a 100-point scale) from baseline.

    DENOMINATOR: All patients aged 18 years or older undergoing elective primary TKA surgery who completed knee-related PROMs (KOOS-Pain, KOOS-ADL, KOOS-PS, KOOS-JR or other validated measure) to measure knee pain and/or function up to 90 days prior to and 9-15 months after the surgery.

    DENOMINATOR EXCLUSION: Patients under 18 years of age; emergent (non-elective) TKA; revision TKA surgery; knee pain and/or function PROMs not completed up to 90 days prior to and 9-15 months after surgery.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    CCOME4 Patient-Reported Pain and/or Function Improvement after ACLR Surgery

    QUALITY DOMAIN: Person and Caregiver Centered Experience and Outcomes

    TYPE: Patient Reported Outcome HIGH

    PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

    NUMERATOR: Patients whose knee pain and/or function scores at 9-15 months post-op improved by at least 10% (e.g., 10 points on a 100-point scale) from baseline.

    DENOMINATOR: All patients 13 years of age and older undergoing elective primary ACLR surgery who completed knee-related PROMs (e.g., KOOS-Pain, KOOS-ADL, KOOS-PS, KOOS-JR) to measure knee pain/or function up to 90 days prior to and 9-15 months after the surgery.

    DENOMINATOR EXCLUSION: Patients under 13 years of age; revision ACLR surgery; knee pain and/or function PROMs not completed up to 90 days prior to and 9-15 months after surgery.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    CCOME6 Patient-Reported Pain and/or Function Improvement after APM Surgery

    QUALITY DOMAIN: Person and Caregiver Centered Experience and Outcomes

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary anterior cruciate ligament reconstruction (ALCR) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

    NUMERATOR: All patients 13 years of age and older undergoing elective primary APM surgery who completed knee-related PROMs (e.g., KOOS-Pain, KOOS-ADL, KOOS-PS, KOOS-JR) to measure knee pain/or function up to 90 days prior to and 9-15 months after the surgery.

    DENOMINATOR: Percentage of patients 13 years of age and older who obtained at least a 10% improvement in knee pain and/or function as measured by validated patient-reported outcome measures (PROMs) completed up to 90 days prior to and 9 to 15 months after undergoing primary arthroscopic partial meniscectomy (APM) surgery. PROMs include any validated measures of knee-related measures of pain and/or function, such as KOOS-Pain, KOOS-ADL, KOOS-PS, and KOOS-JR.

    DENOMINATOR EXCLUSION: Patients under 13 years of age; revision APM surgery; knee pain and/or function PROMs not completed up to 90 days prior to and 9-15 months after surgery.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    IROMS11 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury patients treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.

    NUMERATOR: The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their KOS change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

    DENOMINATOR: The total number of all patients with knee injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.

    DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE, CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 2

    RISK ADJUSTED: Yes

     

    IROMS13 Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

    NUMERATOR: The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their LEFS change score (MCID ≥ 9) from their initial visit to their final visit in PT/OT practice or PT/OT group during the observation window.

    DENOMINATOR: The total number of patients with hip, leg, or ankle injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

    DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

    CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 2

    RISK ADJUSTED: Yes

     

    IROMS15 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).

    NUMERATOR: The total number of neck pain/injury patients evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

    DENOMINATOR: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported. Additionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

    DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

    CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 2

    RISK ADJUSTED: Yes

     

    IROMS17 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

    NUMERATOR: The total number of patients with low back pain to not achieve an MCID in their MDQ change score (MCID >6) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

    DENOMINATOR: The total number of patients with low back pain evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

    DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

    CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 2

    RISK ADJUSTED: Yes

     

    IROMS19 Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported. Additionally, a risk-adjusted DASH change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).These measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

    NUMERATOR: The total number of patients with arm, shoulder, or hand injuries to not achieve an MCID in their DASH change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

    DENOMINATOR: The total number of surgical patients with arm, shoulder, or hand injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

    DENOMINATOR EXCLUSION: Exclude patients who did not complete 2 or more surveys. Patients will be excluded if they are non-English speaking and translation services are not available, if they are unable to read or have a mental impairment that compromises their understanding.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE, INVERSE MEASURE: Yes

    CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 2

    RISK ADJUSTED: Yes

     

    MEX4 Bunion Outcome – Adult and Adolescent

    QUALITY DOMAIN: Effective Clinical Care TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients with a who have a hallux valgus (bunion) deformity causing pain

    NUMERATOR: Patients who were evaluated for hallux deformity Performance Met: Patient experienced less pain by pain scale 181A Denominator Exception: Clinician documented that the patient was not an eligible candidate for treatment of hallux deformity 181B Performance Not Met: Patient did not experience either improvement in pain scale or improvement in foot function index. 181C

    DENOMINATOR: All patients with a contracted hallux or digit hallux valgus Denominator Criteria (Eligible Cases)Diagnosis for hallux deformity M20.11, M20.12, M20.21, M20.22, M20.5X2, M20.31, M20.32, Q74.2, Q66.6, Q66.3 and Patients who have had at least two visits during the reporting period WITHOUT Telehealth Modifier: GQ, GT

    DENOMINATOR EXCLUSION: None

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    MEX5 Hammer Toe Outcome

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Patient Reported Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Percentage of patients who have a painful hammer toe, claw toe, mallet toe or other lesser toe deformity causing disability

    NUMERATOR: Performance Met: Patient experienced less pain by pain scale 183A. Denominator Exception: Clinician documented that patient was not an eligible candidate for treatment of hammer toe 183B OR Performance Not Met: Patient did not experience either improvement in pain scale or improvement in foot function index. 183C

    DENOMINATOR: All patients with a contracted lesser digit (Eligible Cases)

    Diagnosis for contracted digit Q66.89, M20.41, M20.42, M20.51, M20.5×2, M20.61, M20.62 AND Patients who have had at least two visits during the reporting period WITHOUT Telehealth Modifier: GQ, GT

    DENOMINATOR EXCLUSION: None

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    SPINETRACK4 Percent of patients meeting SCB thresholds for back or neck pain

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in back or neck pain following a spine surgical intervention (cervical or lumbar)

    NUMERATOR: Number of patients who have a final value of 3.5 or less, have at least a 2.5 point improvement, or a at least a 41.4% improvement in back or at least a 3.5 point improvement in neck pain on NRS measures at least 6 months after the intervention.

    DENOMINATOR: Any patient >18 years of age who underwent a spinal fusion procedure using any method.

    DENOMINATOR EXCLUSION: Those patients who underwent a spinal fusion procedure without back or neck pain, measured as ≤3 on a numeric rating scale (e.g., patients being treated primarily for myelopathy). Those patients who had not yet reached the minimum 6-month follow-up time point.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

     

    SPINETRACK6 Percent of patients meeting SCB thresholds for pain-related disability (ODI/NDI)

    QUALITY DOMAIN: Effective Clinical Care

    TYPE: Outcome

    HIGH PRIORITY: Yes, Outcome

    DESCRIPTION: Calculation of the percent of patients who meet the substantial clinical benefit (SCB) thresholds for improvement in pain-related disability following a spine surgical intervention (cervical or lumbar)

    NUMERATOR: Number of patients who have at least an 18.8 point improvement, at least a 36.8% improvement, or final disability value below 31.3 measured by ODI or at least a 9.5 point improvement on NDI questionnaires at least 6 months after the intervention.

    DENOMINATOR: Any patient >18 years of age who underwent a spinal fusion procedure using any method.

    DENOMINATOR EXCLUSION: Those patients who underwent a spinal fusion procedure without market disability, measured as ≤30 on Oswestry or neck disability questionnaires (e.g., patients being treated primarily for myelopathy). Those patients who had not yet reached the minimum 6-month follow-up time point.

    MEANINGFUL MEASURE AREA: Patient Reported Functional Outcome

    PROPORTIONAL MEASURE: Yes

    INVERSE MEASURE. CONTINUOUS VARIABLE MEASURE, RATIO MEASURE: No

    PERFORMANCE RATE: 1

    RISK ADJUSTED: No

  • MIPS MEASURES

    All measures below were approved by CMS, and qualify for 2019 MIPS Reporting Program credit


    MIPS Q001: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period

    Measure Developer/Steward: NCQA

     

    MIPS Q039: Screening for Osteoporosis for Women Aged 65-85 Years of Age

    Type:Process

    High Priority:No

    Quality Domain: Effective Clinical Care

    Description: Percentage of female patients age 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis. 

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q109: Diabetes: Osteoarthritis (OA): Function and Pain Assessment

    Type: Process

    High Priority: Yes

    Quality Domain: PCCEO

    Description: Percentage of patient visits for patients aged 21 years and older with a diagnosis of Osteoarthritis (OA) with assessment for function and pain

    Measure Developer/Steward: American Academy of Orthopedic Surgeons

    MIPS Q110: Preventive Care and Screening: Influenza Immunization

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization

    Measure Developer/Steward: AMA-PCPI 

     

    MIPS Q111: Pneumococcal Vaccination Status for Older Adults

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine

    Measure Developer/Steward: NCQA

     

    MIPS Q112: Breast Cancer Screening

    Type: Process

    Quality Domain: ECC

    High Priority Measure: No

    Description: Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer.

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q113: Colorectal Cancer Screening

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer

    Measure Developer/Steward: NCQA

     

    MIPS Q117: Diabetes: Eye Exam

    Type: Process

    Quality Domain: ECC 

    High Priority: No

    Description:Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period.

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q119: Diabetes: Medical Attention for Nephropathy

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description:The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy- Neurological

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 months

    Measure Developer/Steward: American Podiatric Medical Association

     

    MIPS Q127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention- Evaluation of Footwear

    Type: Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizing

    Measure Developer/Steward: American Podiatric Medical Association

     

    MIPS Q128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter

    Normal Parameters:
    Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q130: Documentation of Current Medications in the Medical Record

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of visits for patients aged 18 years and older for which the eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q131: Pain Assessment and Follow-Up

    Type:Process

    Quality Domain: CCC

    High Priority: No

    Description:Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

    Measure Developer/Steward: QIP/QIO

     

    MIPS Q143: Oncology: Medical and Radiation- Pain Intensity Quantified

    Type:Process

    Quality Domain: PCCEO

    High Priority Measure: Yes

    Description:Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified

    Measure Developer/Steward: Physician Consortium for Performance Improvement

     

    MIPS Q154: Falls: Risk Assessment

    Type:Process

    Quality Domain: PS

    High Priority Measure: Yes

    Description:Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q155: Falls: Plan of Care

    Type:Process

    Quality Domain: CCC

    High Priority Measure: Yes

    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

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q177: Rheumatoid Arthritis (RA): Periodic Assessment of Disease Activity

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease activity within 12 months

    Measure Developer/Steward: American College of Rheumatology

     

    MIPS Q178: Rheumatoid Arthritis (RA): Functional Status Assessment

    Type:Process

    Quality Domain: ECC

    Description:Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) whom a functional status assessment was performed at least once within 12 months

    Measure Developer/Steward: American College of Rheumatology

     

    MIPS Q179: Rheumatoid Arthritis (RA): Assessment and Classification of Disease Prognosis

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients aged 18 years and older with a diagnosis of rheumatoid arthritis (RA) who have an assessment and classification of disease prognosis at least once within 12 months

    Measure Developer/Steward: American College of Rheumatology

     

    MIPS Q182: Functional Outcome Assessment

    Type:Process

    Quality Domain: CCC

    High Priority Measure: Yes

    Description: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 on the date of the identified deficiencies

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q217 Functional Status Change for Patients with Knee Impairments

    Type:Outcome

    High Priority:Yes

    Quality Domain:CCC

    Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (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 survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q218 Functional Status Change for Patients with Hip Impairments

    Type: Outcome

    High Priority:Yes

    Quality Domain:CCC

    Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (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 survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q219 Functional Status Change for Patients with Lower Leg, Foot, or Ankle

    Impairments

    Type:  Outcome

    High Priority:Yes

    Quality Domain:CCC

    Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (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 survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q220 Functional Status Change for Patients with Low Back Impairments

    Type:Outcome

    High Priority: Yes 

    Quality Domain:CCC

    Description:A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (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 by to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q221 Functional Status Change for Patients with Shoulder Impairments

    Type:Outcome

    High Priority:Yes

    Quality Domain:CCC

    Description: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) (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 survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q222 Functional Status Change for Patients with Elbow, Wrist, or Hand

    Impairments

    Type:Outcome

    High Priority:Yes

    Quality Domain: CCC

    Description:A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (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 survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q223 Functional Status Change for Patients with General Orthopedic Impairments

    Type:Outcome

    High Priority:Yes

    Quality Domain:CCC

    Description:A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients aged 14 years+ with general orthopedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopedic impairment). The change in FS is assessed using the General Orthopedic FS PROM (patient reported outcome measure) (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 survey)

    Measure Developer/Steward: Focus on Therapeutic Outcomes, Inc.

     

    MIPS Q226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

    Type: Process

    Quality Domain: Community/Population Health

    Description: Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within24 months AND who received cessation counseling intervention if identified as a tobacco user

    Measure Developer/Steward: AMA-PCPI

     

    MIPS Q236: Controlling High Blood Pressure

    Type: Intermediate Outcome

    Quality Domain: Effective Clinical Care

    Description: Percentage of patients 18 – 85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (< 140/90 mmHg) during the measurement period       

    Measure Developer/Steward: NCQA

     

    MIPS Q238: Use of High-Risk Medications in the Elderly

    Type: Process

    Quality Domain: PS

    Description: Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications.

    Measure Developer/Steward: National Committee for Quality Assurance

     

    MIPS Q268: Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:All female patients of childbearing potential (12 – 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q281: Dementia: Cognitive Assessment

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period

    Measure Developer/Steward: Physician Consortium for Performance Improvement

     

    MIPS Q282: Dementia: Functional Status Assessment

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of functional status is performed and the results reviewed at least once within a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q283: Dementia: Neuropsychiatric Symptom Assessment

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:Percentage of patients, regardless of age, with a diagnosis of dementia and for whom an assessment of neuropsychiatric symptoms is performed and results reviewed at least once in a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q286: Dementia: Counseling Regarding Safety Concerns

    Type:Process

    Quality Domain: PS

    High Priority: Yes

    Description:Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q288: Dementia: Caregiver Education and Support

    Type:Process

    Quality Domain: CCC

    High Priority: Yes

    Description:Percentage of patients, regardless of age, with a diagnosis of dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND referred to additional resources for support within a 12 month period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q290: Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:All patients with a diagnosis of Parkinson’s disease who were assessed for psychiatric symptoms (e.g., psychosis, depression, anxiety disorder, apathy, or impulse control disorder) in the last 12 months

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q291: Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment

    Type:Process

    High Priority: No

    Quality Domain: ECC

    Description:All patients with a diagnosis of Parkinson’s disease who were assessed for cognitive impairment or dysfunction in the last 12 months

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q293: Parkinson’s Disease: Rehabilitative Therapy Options

    Type:Process

    Quality Domain: CCC

    High Priority: Yes

    Description:All patients with a diagnosis of Parkinson’s disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the last 12 months

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q317 Preventive Care and Screening: Screening for High blood Pressure and Follow-Up documented

    Type:Process

    High Priority:No

    Quality Domain: CPH

    Description:Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS 318: Falls: Screening for Future Fall Risk

    Type: Process

    Quality Domain: Patient Safety

    Description: Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period.

    Measure Developer/Steward: PCPI & NCQA

     

    MIPS Q358 Patient-Centered Surgical Risk Assessment and communication

    Type:Process

    High Priority:Yes 

    Quality Domain: Person & Caregiver-Centered Experience & Outcome

    Description:Percentage of patients who underwent a non-emergency surgery who had their personalized risks of postoperative complications assessed by their surgical team prior to surgery using a clinical data-based, patient-specific risk calculator and who received personal discussion of those risks with the surgeon

    Measure Developer/Steward: American College of Surgeons

     

    MIPS Q370: Depression Remission at Twelve Months

    Type:Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description:Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment.

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q371: Depression Utilization of the PHQ-9 Tool

    Type:Process

    Quality Domain: ECC

    High Priority: No

    Description:Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q374: Closing the Referral Loop: Receipt of Specialist Report

    Type: Process

    Quality Domain: Communication and Care Coordination

    Description: Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

    Measure Developer/Steward: AMA, LOINC®, LOINC®MIPS


    Q375: Functional Status Assessment for Total Knee Replacement

    Type:Process

    Quality Domain: PCCEO

    High Priority: Yes

    Description:Percentage of patients 18 years of age and older with primary total knee arthroplasty (TKA) who completed baseline and follow-up patient-reported functional status assessments

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q376: Functional Status Assessment for Total Hip Replacement

    Type:Process

    Quality Domain: PCCEO

    High Priority: Yes

    Description:Percentage of patients 18 years of age and older with primary total hip arthroplasty (THA) who completed baseline and follow-up patient-reported functional status assessments

    Measure Developer/Steward: Centers for Medicare & Medicaid Services

     

    MIPS Q382: Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment

    Type:Process

    Quality Domain: PS

    High Priority: Yes

    Description:Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk

    Measure Developer/Steward: Physician Consortium for Performance Improvement

     

    MIPS Q398: Optional Asthma Control

    Type:Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description:Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age-appropriate patient-reported outcome tools and not at risk for exacerbation

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q402: Tobacco Use and Help with Quitting Among Adolescents

    Type: Process

    Quality Domain: Community / Population Health

    Description: The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

    Measure Developer/Steward: NCQA

     

    MIPS Q411: Depression Remission at Six Months

    Type:Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description:Adult patients age 18 years and older with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at six months defined as a PHQ-9 score less than 5. This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment. This measure additionally promotes ongoing contact between the patient and provider as patients who do not have a follow-up PHQ-9 score at six months (+/- 30 days) are also included in the denominator

    Measure Developer/Steward: Minnesota Community Measurement

     

    MIPS Q412: Documentation of Signed Opioid Treatment Agreement

    Type: Process

    Quality Domain: Effective Clinical Care

    Description: All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

    Measure Developer/Steward: American Academy of Neurology Institute

     

    MIPS Q431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

    Type: Process

    Quality Domain: Community/ Population Health

    Description: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user

    Measure Developer/Steward: AMA-PCPI 

    MIPS Q435: Quality of Life Assessment For Patients With Primary Headache Disorders

    Type:Outcome

    Quality Domain: ECC

    High Priority: Yes

    Description:Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q444: Medication Management for People with Asthma

    Type:Process

    Quality Domain: ECR

    High Priority: Yes

    Description:The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on for at least 75% of their treatment period

    Measure Developer/Steward: American Academy of Neurology

     

    MIPS Q469 Average Change in Functional Status Following Lumbar Fusion Surgery

    Type:Outcome

    High Priority:Yes

    Quality Domain:Person & Caregiver-Centered Experience & Outcome

    Description:The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2. 1a) for patients 18 years of age and older who had a lumbar fusion procedure

    Measure Developer/Steward: Minnesota Community Measurement.

     

    MIPS Q470 Average Change in Functional Status Following Total Knee Replacement

    Type:Outcome

    High Priority:Yes 

    Quality Domain:Person & Caregiver-Centered Experience & Outcome

    Description:The average change (preoperative to postoperative) in functional status using the Oxford Knee Score (OKS) for patients age 18 and older who had a primary total knee replacement

    Measure Developer/Steward: Minnesota Community Measurement.

     

    MIPS Q471 Average Change in Functioanl Status Following Lumbar Discectomy/Laminotomy Surgery

    Type:Outcome

    High Priority:Yes

    Quality Domain:Person & Caregiver-Centered Experience & Outcome

    Description:The average change (preoperative to postoperative) in functional status using the Oswestry Disability Index (ODI version 2.1a) for patients age 18 and older who had lumbar discectomy/laminotomy procedure

    Measure Developer/Steward: Minnesota Community Measurement.

     

    MIPS Q473 Average Change in Leg Pain Following Lumbar Fusion Surgery

    Type:Outcome

    High Priority:Yes

    Quality Domain:Person & Caregiver-Centered Experience & Outcome

    Description:The average change (preoperative to one year postoperative) in leg pain for patients 18 years of age or older who had a lumbar fusion procedure

    Measure Developer/Steward: Minnesota Community Measurement.