CMS Measure ID: #461
Collection Type: CQM
Reporting Frequency: Every visit
Outcome: Yes
High Priority: Yes
NQS Domain: Person and Caregiver-Centered Experience Outcomes
Measure Age: > 2 years
Instructions
This measure is to be submitted each time a patient undergoes a lumbar discectomy/laminectomy or 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 or Numeric 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 discectomy/ laminectomy or fusion procedure who are not assessed for leg 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.
Description
For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion 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 or a numeric pain scale at three months (6 to 20 weeks) for discectomy/laminectomy or at one year (9 to 15 months) postoperatively for lumbar fusion patients. Rates are stratified by procedure type; lumbar discectomy/laminectomy or fusion procedure.
Denominator
DENOMINATOR (SUBMISSION CRITERIA 1):
Patients with lumbar discectomy/laminectomy procedure
Patients 18 years of age or older as of January 1 of the denominator identification period who had a lumbar discectomy/laminectomy 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 of 1/1/2022 to 12/31/2022.
Denominator Criteria (Eligible Cases):
Patients age ≥ 18 years by January 1 of the Denominator Identification Period
AND
Patient procedure during the denominator identification period (CPT):63005, 63012, 63017, 63030, 63042, 63047
WITHOUT
Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02
AND NOT
DENOMINATOR EXCLUSIONS:
Patient had a lumbar fusion on the same date as the discectomy/laminectomy procedure (CPT): 22533, 22558, 22586, 22612, 22630, 22633
AND NOT
Patient had cancer, acute fracture or infection related to the lumbar spine OR patient had neuromuscular, idiopathic, or congenital lumbar scoliosis:M1051
–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 (M1051) 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 acute lumbar spine region fracture at the time of the procedure– The following codes would be sufficient to define the Denominator Exclusion (M1051) 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 (M1051) 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 (M1051) ofneuromuscular, 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
DENOMINATOR (SUBMISSION CRITERIA 2):
Patients with lumbar fusion procedure
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
Definition:
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 10/1/2021 to 9/30/2022
Denominator Criteria (Eligible Cases):
Patients aged ≥ 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 (including but not limited to): GQ, GT, 95, POS 02
AND NOT
DENOMINATOR EXCLUSIONS:
Patient had cancer, acute fracture or infection related to the lumbar spine OR patient had neuromuscular, idiopathic, or congenital lumbar scoliosis: M1051
- 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 (M1051) 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 acute lumbar spine region fracture at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (M1051) 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 (M1051) 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 (M1051) 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
NUMERATOR (SUBMISSION CRITERIA 1):
All eligible patients whose leg pain is less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric Pain scale at three months (6 to 20 weeks) 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 or Numeric Pain– A preoperative VAS or Numeric 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 more than three months before the procedure will not be used for measure calculation. If more than one preoperative VAS or Numeric score was obtained, use the VAS or Numeric score that is the most recent and prior to the procedure.
Postoperative Assessment VAS or Numeric Pain– A postoperative VASor Numericpain scale score can be obtained from the patient at three months (6 – 20 weeks) after the date of procedure. Assessment scores obtained prior to six weeks and after 20 weeks postoperatively will not be used for measure calculation. If more than one postoperative VAS or Numeric score was obtained during the six to 20 weeks 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 linkvisual analog scale tool
Numeric Pain Scale –A numeric pain scale is one that asks the patient to rate their pain on a scale of 0 to 10 where zero is “No Pain” and 10 is pain that is intolerable. This type of pain score tool can be administered verbally to the patient and because it does not involve a visual line, multiple modes of administration (e.g., phone, virtual visit, patient portal, verbally in-person, etc.) are acceptable.
Leg Pain Target #1– A patient who is assessed postoperatively at three months (6 to 20 weeks) after the procedure who rates their leg pain as less than or equal to 3.0.
Leg Pain Target #2– A patient who does not meet Leg Pain Target #1 is assessed both preoperatively within 3 months prior to the procedure AND postoperatively at three months (6 to 20 weeks) after the procedure AND the improvement in leg pain is greater than or equal to 5.0 points
NUMERATOR NOTE: It is recommended that both a preoperative and postoperative assessment tool 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 G9943 or G2141 is submitted.
• VAS or Numeric Pain Scale is not administered postoperatively at three months (6 to 20 weeks)
• Leg pain is measured using a different patient reported tool
• Postoperative VAS or Numeric Pain Scale is administered less than six weeks or more than 20 weeks (3 month window)
• Postoperative VAS or Numeric value is greater than 3.0 and no valid preoperative to measure improvement
• Postoperative VAS or Numeric value is greater than 3.0 and preoperative VAS Pain Scale (to measure improvement) 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: Leg pain measured by the Visual Analog Scale (VAS) or Numeric pain scale at three months (6 – 20 weeks) postoperatively was less than or equal to 3.0OR Leg pain measured by the Visual Analog Scale (VAS) or Numeric poain scale within three months preoperatively AND at three months (6 – 20 weeks) postoperatively demonstrated an improvement of 5.0 points or greater(G2140)
OR
Performance Not Met: Leg pain was not measured by the Visual Analog Scale (VAS) or Numeric pain scale at three months (6 – 20 weeks) postoperatively(G9949)
OR
Performance Not Met: Leg pain measured by the Visual Analog Scale (VAS) or Numeric pain scale at three months (6 – 20 weeks) postoperatively was greater than 3.0AND Leg pain measured by the Visual Analog Scale (VAS) or Numeric pain scale within three months preoperatively AND at three months (6 – 20 weeks) postoperatively demonstrated less than an improvement of 5.0 points(G2141)
NUMERATOR (SUBMISSION CRITERIA 2):
All eligible patients whose leg pain is less than or equal to 3.0 OR an improvement of 5.0 points or greater on the Visual Analog Scale (VAS) or Numeric Pain scale 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 or Numeric pain scale score is obtained.
Preoperative Assessment VAS or Numeric Pain– A preoperative VAS or Numeric 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 more than three months before the procedure will not be used for measure calculation. If more than one preoperative VAS or Numeric score was obtained, use the VAS or Numeric score that is the most recent and prior to the procedure.
Postoperative Assessment or Numeric VAS Pain– A postoperative VAS or Numeric pain scale score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained prior to 9 months and after 15 months postoperatively will not be used for measure calculation. If more than one postoperative VAS or Numeric score 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 and at the following link Visual Analog Scale Tool.
Numeric Pain Scale–Anumeric pain scale is one that asks the patient to rate their pain on a scale of 0 to 10 where zero is “No Pain” and 10 is pain that is intolerable. This type of pain score tool can be administered verbally to the patient and because it does not involve a visual line, multiple modes of administration (e.g., phone, virtual visit, patient portal, verbally in-person, etc.) are acceptable
Leg Pain Target #1– A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their leg pain as less than or equal to 3.0.
Leg Pain Target #2– A patient who does not meet Leg Pain Target #1 is assessed both preoperatively within 3 months prior to the procedure AND postoperatively one year (9 to 15 months) after the procedure AND the improvement in leg pain is greater than or equal to 5.0 points.
NUMERATOR NOTE: It is recommended that both a preoperative and postoperative assessment tool be administered to the patient increasing 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 M1052 or G2147 is submitted.
- VAS Pain or Numeric Scale is not administered postoperatively at one year (9 to 15 months)
- Leg pain is measured using a different patient reported functional pain tool
- Postoperative VAS or Numeric Pain scale is administered less than 9 months or greater than 15 months (1 year window)
- Postoperative VAS or Numeric value is greater than 3.0 and no valid preoperative VAS Pain scale for measure improvement
- Postoperative VAS or Numeric value is greater than 3.0 and preoperative VAS or Numeric Pain scale (to measure improvement) 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: Leg pain as measured by the Visual Analog Scale (VAS) or Numeric pain scale at one year (9 to 15 months) postoperatively was less than or equal to 3.0 OR Leg pain measured by the Visual Analog Scale (VAS) or Numeric pain scale within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated an improvement of 5.0 points or greater(G2146)
OR
Performance Not Met: Leg pain was not measured by the Visual Analog Scale (VAS) or Numeric pain scale at one year (9 to 15 months) postoperatively (M1052)
OR
Performance Not Met: Leg pain measured by the VisualAnalog Scale (VAS) or Numeric pain scale at one year (9 to 15 months) postoperatively was greater than 3.0 AND Leg pain measured by the Visual Analog Scale (VAS) or Numeric pain scale within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated less than an improvement of 5.0 points (G2147)