2026 #155 MIPS Measure Falls: Plan of Care

2026 COLLECTION TYPE: 

MERIT-BASED INCENTIVE PAYMENT SYSTEM (MIPS) CLINICAL QUALITY MEASURE (CQM)

‌MEASURE TYPE:

Process – High Priority

‌DESCRIPTION:

Percentage of patients aged 65 years and older with a history of falls who had a plan of care for falls documented within 12 months.

‌INSTRUCTIONS:

‌Reporting Frequency

This measure is to be submitted a minimum of once per performance period for denominator eligible cases as defined in the denominator criteria.

‌Intent and Clinician Applicability:

This measure is intended to reflect the quality of services provided for patients with a history of falls. There is no diagnosis associated with this measure. This measure is appropriate for use in all non-acute settings (with the exception of emergency departments and acute care hospitals). This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions as defined by the numerator based on the services provided and the measure-specific denominator coding.

‌Measure Strata and Performance Rates:

This measure contains one strata defined by a single submission criteria. This measure produces a single performance rate.

‌Implementation Considerations:

For the purposes of MIPS implementation, this patient-process measure is submitted a minimum of once per patient during the performance period. The most advantageous quality data code (QDC) will be used if the measure is submitted more than once.

‌Telehealth:

TELEHEALTH ELIGIBLE: This measure is appropriate for and applicable to the telehealth setting. Patient encounters conducted via telehealth using encounter code(s) found in the denominator encounter criteria are allowed for this measure. Therefore, if the patient meets all denominator criteria for a telehealth encounter, it would be appropriate to include them in the denominator eligible patient population. Telehealth eligibility is at the measure level for inclusion within the denominator eligible patient population and based on the measure specification definitions which are independent of changes to coding and/or billing practices.

‌Measure Submission:

The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third party intermediaries that utilize this collection type for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data. The coding provided to identify the measure criteria: Denominator or Numerator, may be an example of coding that could be used to identify patients that meet the intent of this clinical topic. When implementing this measure, please refer to the ‘Reference Coding’ section to determine if other codes or code languages that meet the intent of the criteria may also be used within the medical record to identify and/or assess patients. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

‌DENOMINATOR:

All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year). Documentation of patient reported history of falls is sufficient.

‌Denominator Criteria (Eligible Cases):

Patients aged ≥ 65 years on date of encounter

AND

Patient screened for future fall risk; documentation of two or more falls in the past year or any fall with injury in the past year: 1100F

AND

Patient encounter during the performance period (CPT or HCPCS): 92540, 92541, 92542, 92548, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, G0402, G0438, G0439

AND NOT

DENOMINATOR EXCLUSIONS:

Hospice services for patient occurred any time during the measurement period: G9720

‌NUMERATOR:

Patients who had a plan of care for falls documented within 12 months.

‌Definitions:

Plan of Care – Must include: balance, strength, and gait training.

Balance, Strength, and Gait Training – Medical record must include: documentation that balance, strength, and gait training/instructions were provided OR referral to an exercise program, which includes at least one of the three components: balance, strength or gait OR referral to physical therapy.

Fall – A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.

‌Numerator Instructions:

All components do not need to be completed during one patient visit, but should be documented in the medical record as having been performed within the past 12 months.

‌Numerator Options:

‌Performance Met: Falls plan of care documented (0518F)

OR

‌Denominator Exception: Patient not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair (0518F with 1P)

OR

‌Performance Not Met: Falls plan of care not documented, reason not otherwise specified (0518F with 8P)

RATIONALE

Interventions to prevent future falls should be documented for the patient with 2 or more falls or injurious falls.