CMS Measure ID: #221
Collection Type: CQM
Reporting Frequency: Once per episode of treatment
Outcome: Yes
High Priority: Yes
NQS Domain: Communication and Care Coordination
Measure Age: > 2 years
Instructions
This outcome measure is to be submitted once per Treatment Episode for all patients with a functional deficit related to the shoulder. This is an outcome measure and its calculation requires submitting of the patient’s FS PROM score, at a minimum, at the start (Initial Evaluation or Intake) and again at the conclusion (Discharge) of a Treatment Episode. The Initial Evaluation score is recorded during the first treatment encounter, and the Discharge score is recorded at or near the conclusion of the final treatment encounter. It is anticipated that Merit- based Incentive Payment System (MIPS) eligible clinicians providing treatment for functional shoulder deficits will submit this measure.
Definitions:
Functional Deficit – Limitation or impairment of physical abilities/function resulting in evaluation and inclusion in a treatment plan of care.
Treatment Episode – A Treatment Episode is defined as beginning with an Initial Evaluation for a functional shoulder deficit, progressing through treatment without interruption (for example, a hospitalization or surgical intervention), and ending with Discharge, signifying that the treatment has been completed. A patient currently under clinical care for a shoulder functional deficit remains in a single Treatment Episode until the Discharge is conducted and documented by the MIPS eligible clinician.
Initial Evaluation – An Initial Evaluation is the first encounter for a functional deficit involving the shoulder and includes an evaluation (CPT 97161, 97162, 97163, 97165, 97166, 97167, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 98940, 98941, 98942, 98943*, 99304, 99305, or 99306), or an Initial Evaluation Status M-code (M1126). A patient presenting with a shoulder impairment, who has had an interruption of a Treatment Episode for the same functional shoulder deficit secondary to an appropriate reason like hospitalization or surgical intervention, is an Initial Evaluation.
Discharge – Discharge is accompanied by a treatment finalization and evaluation completion M-Code (M1013) identifying the close of a Treatment Episode for the same shoulder deficit identified at the Initial Evaluation and documented by a discharge report by the MIPS eligible clinician. An interruption in clinical care for an appropriate reason like hospitalization or surgical intervention requires a discharge from the current Treatment Episode.
Encounter – A visit between the patient and the provider for the purpose of assessing and/or improving a functional deficit.
Patient Reported – The patient directly provides answers to FS PROM items. If the patient cannot reliably respond independently (e.g. in the presence of cognitive deficits), a suitable proxy may provide answers.
The Shoulder FS PROM score – The “Shoulder FS PROM score” may be achieved using one of three forms: the FOTO Shoulder FS PROM computer adaptive test, the FOTO Shoulder FS PROM short form, or an alternative PROM score that is cross-walked to the FOTO Shoulder FS PROM, using a cross-walk form developed by the measure steward. Computer adaptive test (CAT) is recommended to achieve best balance between reduced patient burden and score precision. At least one cross-walk form has been developed by the measure steward and meets scientific standards to successfully link a construct-equivalent PROM using advanced psychometric equating methods.
For more information about the Shoulder FS PROM score forms and to access the components that are available free of charge for use with this MIPS quality measure [e.g., patient-reported outcome measure(s), cross-walking, risk adjustment], visit Public Access to FOTO Measures.
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:
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.
Description
A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in FS is assessed using the FOTO Shoulder FS PROM. 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, individual clinician, and clinic levels to assess quality.
2023 Benchmarks (from 2021 CMS data)
Registry
Topped out: No
Capped at 7: No
Decile 0: 0 – 23.07
Decile 1: 23.08 – 33.77
Minimum: 33.78 – 38.6
Decile 3: 38.61 – 44.34
Decile 4: 44.35 – 49.99
Decile 5: 50 – 55.11
Decile 6: 55.12 – 61.17
Decile 7: 61.18 – 71.42
Decile 8: 71.43 – 86.66
Decile 9: 86.67 – 97.66
Decile 10: 97.67 – 100
Denominator
All patients 14 years and older with shoulder impairments who have initiated a Treatment Episode
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):
All patients aged ≥14 on date of Initial Evaluation
AND
Patient encounter during the performance period identifying evaluation (CPT or M-code): 97161, 97162, 97163, 97165, 97166, 97167, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 98940, 98941, 98942, 98943*, 99304, 99305, 99306, or M1126
AND
With a shoulder impairment and/or diagnosis pertaining to a functional deficit affecting the shoulder: M05.111, M05.112, M05.211, M05.212, M05.311, M05.312, M05.411, M05.412, M05.511, M05.512, M05.611, M05.612, M05.711, M05.712, M05.811, M05.812, M06.011, M06.012, M06.211, M06.212, M06.311, M06.312, M06.811, M06.812, M07.611, M07.612, M08.011, M08.012, M08.211, M08.212, M08.411, M08.412, M08.811, M08.812, M08.911, M08.912, M11.011, M11.012, M11.111, M11.112, M11.211, M11.212, M11.811, M11.812, M12.511, M12.512, M12.811, M12.812, M13.111, M13.112, M13.811, M13.812, M14.611, M14.612, M14.811, M14.812, M19.011, M19.012, M19.111, M19.112, M19.211, M19.212, M21.211, M21.212, M24.011, M24.012, M24.111, M24.112, M24.211, M24.212, M24.311, M24.312, M24.411, M24.412, M24.511, M24.512, M24.611, M24.612, M24.811, M24.812, M25.011, M25.012, M25.211, M25.212, M25.311, M25.312, M25.411, M25.412, M25.511, M25.512, M25.611, M25.612, M25.711, M25.712, M25.811, M25.812, M61.011, M61.012, M61.111, M61.112, M61.211, M61.212, M61.311, M61.312, M61.411, M61.412, M61.511, M61.512, M62.011, M62.012, M62.111, M62.112, M62.211, M62.212, M62.411, M62.412, M62.511, M62.512, M63.811, M63.812, M65.111, M65.112, M65.811, M65.812, M66.111, M66.112, M66.211, M66.212, M66.311, M66.312, M66.811, M66.812, M67.211, M67.212, M67.311, M67.312, M67.411, M67.412, M67.811, M67.812, M67.813, M67.814, M67.911, M67.912, M70.811, M70.812, M70.911, M70.912, M71.011, M71.012, M71.111, M71.112, M71.311, M71.312, M71.811, M71.812, M75.01, M75.02, M75.101, M75.102, M75.111, M75.112, M75.121, M75.122, M75.21, M75.22, M75.31, M75.32, M75.41, M75.42, M75.51, M75.52, M75.81, M75.82, M75.91, M75.92, M80.011D, M80.011G, M80.011K, M80.011P, M80.011S, M80.012D, M80.012G, M80.012K, M80.012P, M80.012S, M80.811D, M80.811G, M80.811K, M80.811P, M80.811S, M80.812D, M80.812G, M80.812K, M80.812P, M80.812S, M84.311D, M84.311G, M84.311K, M84.311P, M84.311S, M84.312D, M84.312G, M84.312K, M84.312P, M84.312S, M93.211, M93.212, M93.811, M93.812, M93.911, M93.912, M94.211, M94.212, M94.8X1, M97.31XD, M97.31XS, M97.32XD, M97.32XS, S40.011A, S40.011D, S40.011S, S40.012A, S40.012D, S40.012S, S42.101D, S42.101G, S42.101K, S42.101P, S42.101S, S42.102D, S42.102G, S42.102K, S42.102P, S42.102S, S42.111D, S42.111G, S42.111K, S42.111P, S42.111S, S42.112D, S42.112G, S42.112K, S42.112P, S42.112S, S42.114D, S42.114G, S42.114K, S42.114P, S42.114S, S42.115D, S42.115G, S42.115K, S42.115P, S42.115S, S42.121D, S42.121G, S42.121K, S42.121P, S42.121S, S42.122D, S42.122G, S42.122K, S42.122P, S42.122S, S42.124D, S42.124G, S42.124K, S42.124P, S42.124S, S42.125D, S42.125G, S42.125K, S42.125P, S42.125S, S42.131D, S42.131G, S42.131K, S42.131P, S42.131S, S42.132D, S42.132G, S42.132K, S42.132P, S42.132S, S42.134D, S42.134G, S42.134K, S42.134P, S42.134S, S42.135D, S42.135G, S42.135K, S42.135P, S42.135S, S42.141D, S42.141G, S42.141K, S42.141P, S42.141S, S42.142D, S42.142G, S42.142K, S42.142P, S42.142S, S42.144D, S42.144G, S42.144K, S42.144P, S42.144S, S42.145D, S42.145G, S42.145K, S42.145P, S42.145S, S42.151D, S42.151G, S42.151K, S42.151P, S42.151S, S42.152D, S42.152G, S42.152K, S42.152P, S42.152S, S42.154D, S42.154G, S42.154K, S42.154P, S42.154S, S42.155D, S42.155G, S42.155K, S42.155P, S42.155S, S42.191D, S42.191G, S42.191K, S42.191P, S42.191S, S42.192D, S42.192G, S42.192K, S42.192P, S42.192S, S42.201D, S42.201G, S42.201K, S42.201P, S42.201S, S42.202D, S42.202G, S42.202K, S42.202P, S42.202S, S42.211D, S42.211G, S42.211K, S42.211P, S42.211S, S42.212D, S42.212G, S42.212K, S42.212P, S42.212S, S42.214D, S42.214G, S42.214K, S42.214P, S42.214S, S42.215D, S42.215G, S42.215K, S42.215P, S42.215S, S42.221D, S42.221G, S42.221K, S42.221P, S42.221S, S42.222D, S42.222G, S42.222K, S42.222P, S42.222S, S42.224D, S42.224G, S42.224K, S42.224P, S42.224S, S42.225D, S42.225G, S42.225K, S42.225P, S42.225S, S42.231D, S42.231G, S42.231K, S42.231P, S42.231S, S42.232D, S42.232G, S42.232K, S42.232P, S42.232S, S42.241D, S42.241G, S42.241K, S42.241P, S42.241S, S42.242D, S42.242G, S42.242K, S42.242P, S42.242S, S42.251D, S42.251G, S42.251K, S42.251P, S42.251S, S42.252D, S42.252G, S42.252K, S42.252P, S42.252S, S42.254D, S42.254G, S42.254K, S42.254P, S42.254S, S42.255D, S42.255G, S42.255K, S42.255P, S42.255S, S42.261D, S42.261G, S42.261K, S42.261P, S42.261S, S42.262D, S42.262G, S42.262K, S42.262P, S42.262S, S42.264D, S42.264G, S42.264K, S42.264P, S42.264S, S42.265D, S42.265G, S42.265K, S42.265P, S42.265S, S42.271D, S42.271G, S42.271K, S42.271P, S42.271S, S42.272D, S42.272G, S42.272K, S42.272P, S42.272S, S42.291B, S42.291D, S42.291G, S42.291K, S42.291P, S42.291S, S42.292D, S42.292G, S42.292K, S42.292P, S42.292S, S42.294D, S42.294G, S42.294K, S42.294P, S42.294S, S42.295D, S42.295G, S42.295K, S42.295P, S42.295S, S42.91XD, S42.91XG, S42.91XK, S42.91XP, S42.91XS, S42.92XD, S42.92XG, S42.92XK, S42.92XP, S42.92XS, S43.001A, S43.001D, S43.001S, S43.002A, S43.002D, S43.002S, S43.004D, S43.004S, S43.005D, S43.005S, S43.011A, S43.011D, S43.011S, S43.012A, S43.012D, S43.012S, S43.014D, S43.014S, S43.015D, S43.015S, S43.021A, S43.021D, S43.021S, S43.022A, S43.022D, S43.022S, S43.024D, S43.024S, S43.025D, S43.025S, S43.031A, S43.031D, S43.031S, S43.032A, S43.032D, S43.032S, S43.034D, S43.034S, S43.035D, S43.035S, S43.081A, S43.081D, S43.081S, S43.082A, S43.082D, S43.082S, S43.084D, S43.084S, S43.085D, S43.085S, S43.101D, S43.101S, S43.102D, S43.102S, S43.111A, S43.111D, S43.111S, S43.112A, S43.112D, S43.112S, S43.121D, S43.121S, S43.122D, S43.122S, S43.131D, S43.131S, S43.132D, S43.132S, S43.141D, S43.141S, S43.142D, S43.142S, S43.151D, S43.151S, S43.152D, S43.152S, S43.201A, S43.201D, S43.201S, S43.202A, S43.202D, S43.202S, S43.204D, S43.204S, S43.205D, S43.205S, S43.211A, S43.211D, S43.211S, S43.212A, S43.212D, S43.212S, S43.214D, S43.214S, S43.215D, S43.215S, S43.221D, S43.221S, S43.222D, S43.222S, S43.224D, S43.224S, S43.225D, S43.225S, S43.301A, S43.301D, S43.301S, S43.302A, S43.302D, S43.302S, S43.304D, S43.304S, S43.305D, S43.305S, S43.311A, S43.311D, S43.311S, S43.312A, S43.312D, S43.312S, S43.314D, S43.314S, S43.315D, S43.315S, S43.391A, S43.391D, S43.391S, S43.392A, S43.392D, S43.392S, S43.394D, S43.394S, S43.395D, S43.395S, S43.401A, S43.401D, S43.401S, S43.402A, S43.402D, S43.402S, S43.411A, S43.411D, S43.411S, S43.412A, S43.412D, S43.412S, S43.421A, S43.421D, S43.421S, S43.422A, S43.422D, S43.422S, S43.431A, S43.431D, S43.431S, S43.432A, S43.432D, S43.432S, S43.491A, S43.491D, S43.491S, S43.492A, S43.492D, S43.492S, S43.51XA, S43.51XD, S43.51XS, S43.52XA, S43.52XD, S43.52XS, S43.61XA, S43.61XD, S43.61XS, S43.62XA, S43.62XD, S43.62XS, S43.81XA, S43.81XD, S43.81XS, S43.82XA, S43.82XD, S43.82XS, S43.91XA, S43.91XD, S43.91XS, S43.92XA, S43.92XD, S43.92XS, S46.001A, S46.001D, S46.001S, S46.002A, S46.002D, S46.002S, S46.011A, S46.011D, S46.011S, S46.012A, S46.012D, S46.012S, S46.091A, S46.091D, S46.091S, S46.092A, S46.092D, S46.092S, S46.101A, S46.101D, S46.101S, S46.102A, S46.102D, S46.102S, S46.111A, S46.111D, S46.111S, S46.112A, S46.112D, S46.112S, S46.191A, S46.191D, S46.191S, S46.192A, S46.192D, S46.192S, S46.801A, S46.801D, S46.801S, S46.802A, S46.802D, S46.802S, S46.811A, S46.811D, S46.811S, S46.812A, S46.812D, S46.812S, S46.891A, S46.891D, S46.891S, S46.892A, S46.892D, S46.892S, S46.901A, S46.901D, S46.901S, S46.902A, S46.902D, S46.902S, S46.911A, S46.911D, S46.911S, S46.912A, S46.912D, S46.912S, S46.921A, S46.921D, S46.921S, S46.922A, S46.922D, S46.922S, S46.991A, S46.991D, S46.991S, S46.992A, S46.992D, S46.992S, S47.1XXD, S47.1XXS, S47.2XXD, S47.2XXS, S49.001D, S49.001G, S49.001K, S49.001P, S49.001S, S49.002D, S49.002G, S49.002K, S49.002P, S49.002S, S49.011D, S49.011G, S49.011K, S49.011P, S49.011S, S49.012D, S49.012G, S49.012K, S49.012P, S49.012S, S49.021D, S49.021G, S49.021K, S49.021P, S49.021S, S49.022D, S49.022G, S49.022K, S49.022P, S49.022S, S49.031D, S49.031G, S49.031K, S49.031P, S49.031S, S49.032D, S49.032G, S49.032K, S49.032P, S49.032S, S49.041D, S49.041G, S49.041K, S49.041P, S49.041S, S49.042D, S49.042G, S49.042K, S49.042P, S49.042S, S49.091D, S49.091G, S49.091K, S49.091P, S49.091S, S49.092D, S49.092G, S49.092K, S49.092P, S49.092S, S49.81XA, S49.81XD, S49.81XS, S49.82XA, S49.82XD, S49.82XS, S49.91XA, S49.91XD, S49.91XS, S49.92XA, S49.92XD, S49.92XS, Z47.31, Z89.231, Z89.232, Z96.611, Z96.612
AND
Discharge/discontinuation of the episode of care documented in the medical record (M-code): M1013
AND NOT
DENOMINATOR EXCLUSIONS:
Documentation stating patient has a diagnosis of a degenerative neurological condition such as ALS, MS, or Parkinson’s diagnosed at any time before or during the episode of care: M1127
OR
Patient unable to complete the Shoulder FS PROM at Initial Evaluation and/or Discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility and an adequate proxy is not available: G9735
Numerator
Patients who were presented with the Shoulder FS PROM at Initial Evaluation (Intake) and at or near Discharge (Status) for the purpose of calculating the patient’s Residual Score.
Definitions:
Functional Status (FS) Score – This is the Shoulder FS PROM score as described under Instructions Definitions.
FS Change Score – The “FS Change Score” is calculated by subtracting the FS Score at Initial Evaluation from the FS Score at Discharge.
Predicted FS Change Score – The “Predicted FS Change Score” is calculated by accounting for the influence of multiple patient characteristics as designated by the risk adjustment model. For each patient completing the Shoulder FS PROM at Initial Evaluation (Intake), the predictive model provides a risk-adjusted prediction of FS change at Discharge.
Residual Score – The “Residual Score” is calculated by subtracting the the Predicted FS Change Score from the FS Change Score (i.e, actual minus predicted). The “Residual Score”, which is in the same units as the FS Score, should be interpreted as the amount of FS change that is different than the amount of change that was predicted given the risk-adjustment variables of the patient being treated. Residual Scores of zero (0) or greater (> 0) should be interpreted as FS Change Scores that met or exceeded what was predicted. Residual scores less than zero (< 0) should be interpreted as FS Change Scores that were less than predicted. Aggregated Residual Scores allow meaningful comparisons amongst clinicians or clinics
Numerator Options:
Performance Met: Residual Score for the shoulder impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) (G8663)
OR
Denominator Exception: Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record (M1128)
OR
Denominator Exception: Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery (M1129)
OR
Denominator Exception: Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown) (M1130)
OR
Denominator Exception: Patient refused to participate (G9734)
OR
Performance Not Met: Residual Score for the shoulder impairment successfully calculated and the score was less than zero (< 0) (G8664)
OR
Performance Not Met: Residual Score for the shoulder impairment not measured because the patient did not complete the Shoulder FS PROM at Initial Evaluation and/or near discharge, reason not given (G8666)