Neurosurgical MIPS Specialty Measure Set (2022)

CMS specialty measure sets may be reported as an alternative to reporting 6 separate quality measures. If a measure set has less than 6 measures, eligible groups and clinicians must report all measures in the set. However, if a set has more than 6 measures, participants may choose the 6 measures that best fit their practice. Remember, at least one outcome measure must be reported, regardless of whether or not an outcome measure is included in a measure set.

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
1302022 Measure # 130 Documentation of Current Medications in the Medical RecordyesProcessPercentage of visits for patients aged 18 years and older for which the eligible professional or 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 administrationView
1872022 Measure # 187 Stroke and Stroke Rehabilitation: Thrombolytic TherapynoProcessPercentage of patients aged 18 years and older with a diagnosis of acute ischemic stroke who arrive at the hospital within two hours of time last known well and for whom IV t-PA was initiated within three hours of time last known wellView
2262022 Measure # 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation InterventionnoProcessPercentage of patients aged 18 years and older who were screened for tobacco use one or more times within the measurement period AND who received tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco userView
2602022 Measure # 260 Rate of Carotid Endarterectomy (CEA) for Asymptomatic Patients, without Major Complications (Discharged to Home by Post-Operative Day #2)yesOutcomePercent of asymptomatic patients undergoing CEA who are discharged to home no later than post-operative day #2View
4092022 Measure # 409 Clinical Outcome Post-Endovascular Stroke TreatmentyesOutcomePercentage of patients with a Modified Rankin Score (mRS) score of 0 to 2 at 90 days following endovascular stroke intervention.View
4132022 Measure # 413 Door to Puncture Time for Endovascular Stroke TreatmentyesIntermediate OutcomePercentage of patients undergoing endovascular stroke treatment who have a door to puncture time of 90 minutes or less.View
4592022 Measure # 459 Back Pain After Lumbar Discectomy/LaminotomyyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, back pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperatively.View
4602022 Measure # 460 Back Pain After Lumbar FusionyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar fusion procedure, back pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively
* hereafter referred to as VAS Pain.
View
4612022 Measure # 461 Leg Pain After Lumbar Discectomy/ LaminotomyyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar discectomy/laminectomy procedure, leg pain is rated by the patients as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain scale at three months (6 to 20 weeks) postoperativelyView
4692022 Measure # 469 Functional Status After Lumbar FusionyesPatient Reported OutcomeFor patients 18 years of age and older who had a lumbar 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 one year (9 to 15 months) postoperatively. * hereafter referred to as ODIView
4712022 Measure # 471 Functional Status After Lumbar Discectomy/LaminectomyyesPatient Reported OutcomeFor patients age 18 and older who had lumbar discectomy/laminectomy 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. * hereafter referred to as ODIView
4732022 Measure # 473 Leg Pain After Lumbar FusionyesPatient Reported OutcomeFor patients 18 years of age or older who had a lumbar fusion procedure, leg pain is rated by the patient as less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) Pain* scale at one year (9 to 15 months) postoperatively
* hereafter referred to as VAS Pain.
View

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CMS-2022