2026 #282 MIPS Measure Functional Status Assessment

2026 COLLECTION TYPE:

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

‌MEASURE TYPE:

Process

‌DESCRIPTION:

Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 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 dementia. 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.

‌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 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 with a diagnosis of dementia.

‌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 regardless of age

AND

Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, F01.50, F01.511, F01.518, F01.52, F01.53, F01.54, F01.A0, F01.A11, F01.A18, F01.A2, F01.A3, F01.A4, F01.B0, F01.B11, F01.B18, F01.B2, F01.B3, F01.B4, F01.C0, F01.C11, F01.C18, F01.C2, F01.C3, F01.C4, F02.80, F02.811, F02.818, F02.82, F02.83, F02.84, F02.A0, F02.A11, F02.A18, F02.A2, F02.A3, F02.A4, F02.B0, F02.B11, F02.B18, F02.B2, F02.B3, F02.B4, F02.C0, F02.C11, F02.C18, F02.C2, F02.C3, F02.C4, F03.90, F03.911, F03.918, F03.92, F03.93, F03.94, F03.A0, F03.A11, F03.A18, F03.A2, F03.A3, F03.A4, F03.B0, F03.B11, F03.B18, F03.B2, F03.B3, F03.B4, F03.C0, F03.C11, F03.C18, F03.C2, F03.C3, F03.C4, F10.27, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94

AND

Patient encounter during the performance period (CPT or HCPCS): 78811, 78814, 90791, 90792, 90832, 90834, 90837, 92522, 92523, 92610, 92611, 92612, 92616, 96105, 96112, 96116, 96125, 96130, 96132, 96136, 96138, 96146, 96156, 96158, 96164, 96167, 96170*, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99221, 99222, 99223, 99231, 99232, 99233, 99238, 99239, 99242*, 99243*, 99244*, 99245*, 99252*, 99253*, 99254*, 99255*, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350, 99424, 99426, 99487, 99490, 99491, 99497, A9586, A9601, Q9982, Q9983

‌NUMERATOR:

Patients for whom an assessment of functional status was performed at least once in the last 12 months.

‌Definition:

Assessment of functional status – Functional status is assessed by use of a validated tool, direct assessment of the patient, or by querying a knowledgeable informant. A direct “assessment of functional status” includes an evaluation of the patient’s ability to perform instrumental activities of daily living (IADL) and basic activities of daily living (ADL).

‌Numerator Instructions:

To meet this measure providers must assess BOTH IADL and ADL performance.

1. IADL Assessment (users must meet one of the two below bullets to meet IADL assessment component)
   • To meet the measure’s IADL component using a validated tool, providers must use one of the following tools:
     • Lawton Instrumental Activities of Daily Living Scale
     • Bristol Activities of Daily Living Scale
     • Katz Index of Independence in Activities of Daily Living
     • Functional Activities Questionnaire
     • Functional Independence Measure Instrument
   • To meet the measure’s IADL component using a direct assessment, providers must document 3 out of the following 5 domains.
     • Cleaning or hobbies,
     • Money management,
     • Medication management,
     • Transportation, and
     • Cooking or communication
2. ADL Assessment (users must meet one of the two below bullets to meet ADL assessment component)
   • To meet the measure’s ADL component using a validated tool, providers must use either:
     • Barthel ADL Index
     • Bristol Activities of Daily Living Scale
   • To meet the measure’s ADL component using a direct assessment, providers must document 3 out of the following 7 domains.
     • Grooming,
     • Bathing,
     • Dressing,
     • Eating,
     • Toileting,
     • Gait, and
     • Transferring.

‌NUMERATOR NOTE:

The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Denominator Exception(s) are determined on the date of the denominator eligible encounter. Documentation of advanced stage dementia and caregiver knowledge is limited would meet the measure exception criteria.

‌Numerator Options:‌

Performance Met: Functional status performed once in the last 12 months (G9916)

OR

‌Denominator Exception: Documentation of advanced stage dementia and caregiver knowledge is limited (G9917)

OR

‌Performance Not Met: Functional status not performed, reason not otherwise specified (G9918)

RATIONALE:

Maintaining or increasing physical functioning levels is a desired outcome. This is key to maintaining quality of life and reducing caregiver burden. This requires regular assessment of function in multiple domains. In routine practice, persons with dementia may not be assessed regularly for changes in their ability to perform both basic and instrumental activities of daily living. Frequent and comprehensive assessments will allow health care providers to track these changes and to make timely interventions aimed at preserving function or mitigating disability.
When planning interventions to improve or maintain function, it is important to consider a broad range of causes of functional impairment, including impaired cognition.