|Measure Type||High Priority Measure?||Collection Type(s)|
|Process||yes||Medicare Part B Claims, MIPS CQM|
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
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This measure is to be submitted at each denominator eligible visit occurring during the performance period for patients seen during the performance period. There is no diagnosis associated with this measure. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The documented follow-up plan must be related to the presence of pain, example: “Patient referred to pain management specialist for back pain” or “Return in two weeks for re-assessment of pain”.
Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.
All visits for patients aged 18 years and older
DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs
Denominator Criteria (Eligible Cases): Patients aged ≥ 18 years on date of encounter
Patient encounter during the performance period (CPT or HCPCS): 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96121, 96130, 96131, 96132, 96133, 96136, 96136, 96137, 96138, 96139, 96146, 96150, 96151, 97127*, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98940, 98941, 98942, 98943, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99234, 99235, 99236, 99238, 99239, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, D7140, D7210, G0101, G0402, G0438, G0439
Telehealth Modifier: GQ, GT, 95, POS 02
Patient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present
Pain Assessment – Documentation of a clinical assessment for the presence or absence of pain using a standardized tool is required. A multi-dimensional clinical assessment of pain using a standardized tool may include characteristics of pain; such as: location, intensity, description, and onset/duration.
Standardized Tool – An assessment tool that has been appropriately normed and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS) and Visual Analog Scale (VAS), Patient-Reported Outcomes Measurement Information System (PROMIS).
Follow-Up Plan – A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable OR indicate the initial treatment plan is still in effect. These plans may include pharmacologic, interventional therapies, behavioral, physical medicine and/or educational interventions.
Not Eligible (Denominator Exception) – A patient is not eligible if one or more of the following reason(s) is documented at the time of the encounter:
- Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools
- Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
NUMERATOR NOTE: The standardized tool used to assess the patient’s pain must be documented in the medical record (exception: A provider may use a fraction such as 5/10 for Numeric Rating Scale without documenting this actual tool name when assessing pain for intensity).
Performance Met: Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented (G8730)
Performance Met: Pain assessment using a standardized tool is documented as negative, no follow-up plan required (G8731)
Denominator Exception: Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool at the time of the encounter (G8442)
Denominator Exception: Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible at the time of the encounter (G8939)
Performance Not Met: No documentation of pain assessment, reason not given (G8732)
Performance Not Met: Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given (G8509)