2022 Measure # 460 Back Pain After Lumbar Fusion

Measure Description

For 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.

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Instructions

This measure is to be submitted each time a patient undergoes a lumbar fusion during the denominator identification period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: This measure is a target-based measure with two ways to meet the numerator; either a postoperative VAS Pain score that is less than or equal to 3.0 OR an improvement of 5.0 points or greater from the preoperative to postoperative score. It is expressed as a proportion or rate. Patients having received a lumbar fusion procedure who are not assessed for back pain postoperatively remain in the denominator and are considered as not meeting the target. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures to be utilized for performance calculation.

Measure Submission:

Measure data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

Denominator

Patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar fusion procedure performed during the denominator identification period

Definitions:
Denominator Identification Period – The twelve month period in which eligible patients have a procedure. This allows for enough time for a follow-up assessment to occur during the performance period. The denominator identification period includes dates of procedure 10/1/2018 to 9/30/2019.

Denominator Criteria (Eligible Cases):
Patients age ≥ 18 years by October 1 of the Denominator Identification Period
AND
Patient procedure during the denominator identification period (CPT): 22533, 22558, 22586, 22612, 22630, 22633
WITHOUT
Telehealth Modifier: GQ, GT, 95, POS 02

AND NOT
DENOMINATOR EXCLUSIONS:
AND NOT
Patient had cancer, fracture or infection related to the lumbar spine OR patient had neuromuscular, idiopathic or congenital scoliosis: G9945

– Patients with a diagnosis of lumbar spine region cancer at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of lumbar spine region cancer: C41.2, C41.4, C79.51, C79.52, D16.6, D16.8, D48.0, D49.2

– Patients with a diagnosis of lumbar spine region fracture at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of lumbar spine region fracture: M48.44XA, M48.45XA, M48.46XA, M48.47XA, M48.48XA, M48.54XA, M48.55XA, M48.56XA, M48.57XA, M48.58XA, S22.060A, S22.060B, S22.061A, S22.061B, S22.062A, S22.062B, S22.068A, S22.068B, S22.069A, S22.069B, S22.070A, S22.070B, S22.071A, S22.071B, S22.072A, S22.072B, S22.078A, S22.078B, S22.079A, S22.079B, S22.080A, S22.080B, S22.081A, S22.081B, S22.082A, S22.082B, S22.088A, S22.088B, S22.089A, S22.089B, S24.103A, S24.104A, S24.113A, S24.114A, S24.133A, S24.134A, S24.143A, S24.144A, S24.153A, S24.154A, S32.000A, S32.000B, S32.001A, S32.001B, S32.002A, S32.002B, S32.008A, S32.008B, S32.009A, S32.009B, S32.010A, S32.010B, S32.011A, S32.011B, S32.012A, S32.012B, S32.018A, S32.018B, S32.019A, S32.019B, S32.020A, S32.020B, S32.021A, S32.021B, S32.022A, S32.022B, S32.028A, S32.028B, S32.029A, S32.029B, S32.030A, S32.030B, S32.031A, S32.031B, S32.032A, S32.032B, S32.038A, S32.038B, S32.039A, S32.039B, S32.040A, S32.040B, S32.041A, S32.041B, S32.042A, S32.042B, S32.048A, S32.048B, S32.049A, S32.049B, S32.050A, S32.050B, S32.051A, S32.051B, S32.052A, S32.052B, S32.058A, S32.058B, S32.059A, S32.059B, S32.10XA, S32.10XB, S32.110A, S32.110B, S32.111A, S32.111B, S32.112A, S32.112B, S32.119A, S32.119B, S32.120A, S32.120B, S32.121A, S32.121B, S32.122A, S32.122B, S32.129A, S32.129B, S32.130A, S32.130B, S32.131A, S32.131B, S32.132A, S32.132B, S32.139A, S32.139B, S32.14XA, S32.14XB, S32.15XA, S32.15XB, S32.16XA, S32.16XB, S32.17XA, S32.17XB, S32.19XA, S32.19XB, S32.2XXA, S32.2XXB, S32.9XXA, S32.9XXB, S34.101A, S34.102A, S34.103A, S34.104A, S34.105A, S34.109A, S34.111A, S34.112A, S34.113A, S34.114A, S34.115A, S34.119A, S34.121A, S34.122A, S34.123A, S34.124A, S34.125A, S34.129A, S34.131A, S34.132A, S34.139A, S34.3XXA

– Patients with a diagnosis of lumbar spine region infection at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of lumbar spine region infection: M46.25, M46.26, M46.27, M46.28, M46.35, M46.36, M46.37, M46.38, M46.45, M46.46, M46.47, M46.48, M46.55, M46.56, M46.57, M46.58

– Patients with a diagnosis of lumbar neuromuscular, idiopathic or congenital scoliosis – The following codes would be sufficient to define the Denominator Exclusion (G9945) of neuromuscular, idiopathic or congenital scoliosis: M41.05, M41.06, M41.07, M41.08, M41.45, M41.46, M41.47, M41.115, M41.116, M41.117, M41.125, M41.126, M41.127, M41.25, M41.26, M41.27, Q67.5, Q76.3

Numerator

All eligible patients whose back pain is less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) at one year (9 to 15 months) postoperatively

Definitions:
Measure Assessment Period (Performance Period) – The period of time following the procedure date that is in which a postoperative VAS pain scale score is obtained.
Preoperative Assessment VAS Pain – A preoperative VAS pain scale score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained via a telephone screening or more than three months before the procedure will not be used recent and prior to the procedure.
Postoperative Assessment VAS Pain – A postoperative VAS pain scale score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained via a telephone screening or prior to 9 months and after 15 months postoperatively will not be used for measure calculation. If more than one postoperative VAS was obtained during the 9 to 15 months following the procedure, use the most recent score obtained during the allowable timeframe.
Visual Analog Scale (VAS) – A “visual analog scale” is a continuous line indicating the continuum between two states of being. A copy of the tool can be obtained below or at the following link Visual Analog Scale Tool.
Back Pain Target #1 – A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their back pain as less than or equal to 3.0.
Back Pain Target #2 – A patient who does not meet Back Pain Target #1 is assessed both preoperatively within 3 months prior to the procedure AND postoperatively at one year (9 to 15 months) after the procedure AND the improvement is greater than or equal to 5.0 points.

NUMERATOR NOTE: It is recommended that both a preoperative and postoperative be administered to the patient increasing the chances that one of the numerator targets will be met. The following situations are those in which the numerator target cannot be reached and Performance Not Met G9946 or G2139 is submitted.
•VAS Pain Scale is not administered postoperatively at one year (9 to 15 months)
•Back pain is measured using a different patient reported tool or via telephone screening
•Postop VAS Pain Scale is administered less than nine months or more than 15 months (1 year window)
•Postoperative VAS value is greater than 3.0 and no valid preop to measure change
•Postoperative VAS value is greater than 3.0 and preoperative VAS Pain Scale (to measure change) is administered beyond the three month timeframe prior to and including the date of procedure (e.g. 6 months before procedure)

Numerator Options:

Performance Met: Back pain as measured by the Visual Analog Scale (VAS) at one year (9 to 15 months) postoperatively was less than or equal to 3.0 OR Back pain measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated an improvement of 5.0 points or greater (G2138)

OR

Performance Not Met: Back pain was not measured by the Visual Analog Scale (VAS) at one year (9 to 15 months) postoperatively (G9946)
OR
Performance Not Met: Back pain measured by the Visual Analog Scale (VAS) Pain at one year (9 to 15 months) postoperatively was greater than 3.0 AND Back pain measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated less than an Improvement of 5.0 points (G2139)

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