2023 # 182 Functional Outcome Assessment

CMS Measure ID: #182

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: No

High Priority: Yes

NQS Domain: Communication and Care Coordination

Measure Age: > 2 years

Instructions

This measure is to be submitted each denominator eligible visit for patients seen during the 12 month performance period. The functional outcome assessment is required to be current as defined in the definition section. 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: Patient encounters for this measure conducted via telehealth (e.g., encounters coded with GQ, GT, 95, or POS 02 modifiers) are allowable.

Measure Submission Type:

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 for registry-based submissions; however, these codes may be submitted for those registries that utilize claims data.

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 within two days of the date of the identified deficiencies.

2023 Benchmarks (from 2021 CMS data)

Registry

Topped out: Yes
Capped at 7: Yes

Decile 0: 0 – 2.05
Decile 1: 2.06 – 97.88
Minimum: 97.89 – 99.54
Decile 3: 99.55 – 99.91
Decile 4: 99.92 – 99.99
Decile 10: 100 – 100

Denominator

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

AND

Patient encounter during the performance period (CPT): 92540, 92542, 92546, 92548, 92605, 92607, 92610, 92611, 92612, 92614, 92616, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98940, 98941, 98942, 98943*, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, and 99350

Numerator

Visits where patient has a documented current functional outcome assessment using a standardized tool AND a documented care plan based on the identified functional outcome deficiencies within two days of the assessment

Numerator Instructions:
Documentation of a current functional outcome assessment must include identification of the standardized tool used.

The follow-up plan must still be provided for and discussed with the patient during the qualifying encounter used to evaluate the numerator. However, documentation of the follow-up plan can occur up to two calendar days after the qualifying encounter, in accordance with the policies of an eligible clinician’s practice or health system. All services should be documented during, or as soon as practicable, after the qualifying encounter in order to maintain an accurate medical record.

Definitions:

Standardized Tool – A tool that has been normed and validated. Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS), Disabilities of the Arm, Shoulder and Hand (DASH), EAT-10: A Swallowing Screening Tool, Health Partners Hearing Assessment, Tinneti Performance Oriented Mobility Assessment (POMA), and Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF).

NOTE: A functional outcome assessment is multi-dimensional and quantifies pain, musculoskeletal/neuromusculoskeletal, or speech and language capacity; therefore, the use of a standardized tool assessing pain alone, such as the visual analog scale (VAS), does not meet the criteria of a functional outcome assessment standardized tool.

Table 1. Definitions for Magnitude of Effects, Based on Mean Between-Group Differences

ODI = Oswestry Disability Index; RDQ = Roland Morris Disability Questionnaire; SMD = standardized mean difference; VAS = visual analogue scale

Chou R, Devo R, Friedly J, Skelly A, Hashimoto R, Weimer M ….& Brodt ED. (2017). Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med, 166:493-505

Functional Outcome Assessment – Patient completed questionnaires designed to measure a patient’s limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms.
Current (Functional Outcome Assessment) – A patient having a documented functional outcome assessment utilizing a standardized tool and a care plan if indicated at a qualifying encounter within the previous 30 days.
Functional Outcome Deficiencies – Impairment or loss of function related to musculoskeletal/neuromusculoskeletal capacity, including but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches.
OR
Impairment or loss of function related to speech and language capacity, including but not limited to: swallowing or hearing, and/or balance disorders.
Care Plan – A “care plan” is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations, goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient’s health care problems. Care plans may also be known as a treatment plan.
Not Eligible (Denominator Exception) – A patient is not eligible if one or more of the following reasons(s) is documented at the time of the encounter:
• Patient refuses to participate
• Patient unable to participate in administration of the functional outcome assessment(s)
• Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

NUMERATOR NOTE: The intent of this measure is for a functional outcome assessment tool to be utilized at a minimum of every 30 days but submission is only required at each qualifying encounter due to coding limitations. Therefore, for visits occurring within 30 days of a previously documented functional outcome assessment, the numerator quality- data code G8942 should be used for reporting purposes.

Numerator Options:

Performance Met:

Functional outcome assessment documented as positive using a standardized tool AND a care plan, based on identified deficiencies is documented within two days of the functional outcome assessment (G8539)

OR

Performance Met:

Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required (G8542)

OR

Performance Met:

Functional outcome assessment using a standardized tool is documented within the previous 30 days and a care plan, based on identified deficiencies is documented within two days of the functional outcome assessment (G8942)

OR

Denominator Exception:

Functional outcome assessment NOT documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool at the time of the encounter (G8540)

OR

Denominator Exception:

Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan at the time of the encounter (G9227)

OR

Performance Not Met:

Functional outcome assessment using a standardized tool not documented, reason not given (G8541)

OR

Performance Not Met:

Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented within two days of assessment, reason not given (G8543)