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2026 #459 MIPS Measure Back Pain After Lumbar Surgery

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2026 COLLECTION TYPE:

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

‌MEASURE TYPE:
Patient-Reported Outcome-Based Performance Measure – High Priority

‌Description:

For patients 18 years of age or older who had a lumbar discectomy/laminectomy or fusion procedure, back 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) postoperatively 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.

‌Instructions:

Reporting Frequency:
This measure is to be submitted each time a denominator eligible procedure as defined in the denominator criteria isperformed.

Intent and Clinician Applicability:
This measure is intended to reflect the quality of services provided for patients who undergo a lumbar discectomy/laminectomy or fusion. 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 two strata defined by two submission criteria.
This measure produces two performance rates which are used for a weighted average.

There are 2 Submission Criteria for this measure:
1) Back pain improvement at three months post lumbar discectomy/laminectomy procedure
AND
2) Back pain improvement at one year post lumbar fusion procedure

This measure will be calculated with 2 performance rates:
1) Percentage of lumbar discectomy/laminectomy procedures for which the patient reports back pain 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
2) Percentage of lumbar fusion procedures for which the patient reports back pain less than or equal to 3.0 OR an improvement of 5.0 points or greater on the VAS or Numeric pain scale at one year (9 to 15 months) postoperatively

A weighted average, which is the sum of the performance numerator values divided by the sum of performance denominator values, will be used to calculate performance.

Implementation Considerations:
For the purposes of MIPS implementation, this procedure measure is submitted each time a procedure is performed during the performance period. The most recent quality data code will be used if the measure is submitted more than once.

This measure is a target-based measure with two ways to meet the numerator; either a postoperative VAS Pain score or numeric pain scale 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 back 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.

Telehealth:
NOT TELEHEALTH ELIGIBLE: This measure is not appropriate for nor applicable to the telehealth setting. This measure is procedure based and therefore doesn’t allow for the denominator criteria to be conducted via telehealth. It would be appropriate to remove these patients from 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.

SUBMISSION CRITERIA 1: BACK PAIN IMPROVEMENT AT THREE MONTHS POST LUMBAR DISCECTOMY/LAMINECTOMY PROCEDURE

‌Denominator (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

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 1/1/2025 to 12/31/2025.

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

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: G9945

Reference Coding:

Denominator Exclusion for lumbar fusion on the same date [M1466] may be defined by the following coding, however, other codes/code languages that meet the intent of this component may also be used: 22533, 22558, 22586, 22612, 22630, 22633

Denominator Exclusion for cancer, acute fracture or infection OR neuromuscular, idiopathic, or congenital lumbar scoliosis [G9945] may be defined by the following coding, however, other codes/code languages that meet the intent of this component may also be used:

  • Lumbar Spine Region Cancer:
    C41.2, C41.4, C79.51, C79.52, D16.6, D16.8, D48.0, D49.2
  • Acute 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
  • 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
  • Lumbar 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 (Criteria 1):

    All eligible patients whose back 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 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 VAS or Numeric Pain ― A postoperative VAS or Numeric pain 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.

    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.

    Copies of the pain scale tools can be obtained at the following link: https://helpdesk.mncm.org/helpdesk/KB/View/17776810-spine-surgery-pro-tools

    Back Pain Target #1 ― A patient who is assessed postoperatively at three months (6 to 20 weeks) after the procedure who rates their back pain as less than or equal to 3.0.

    Back Pain Target #2 ― A patient who does not meet Back 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 back 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 G2137 is submitted:

    • VAS or Numeric Pain Scale is not administered postoperatively at three months (6 to 20 weeks)

    • Back 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 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: Back 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 3.0 OR Back 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 an improvement of 5.0 points or greater (G2136)

      OR

      Performance Not Met: Back pain was not measured by the Visual Analog Scale (VAS) or numeric pain scale at three months (6 – 20 weeks) postoperatively (G9943)

      OR

      Performance Not Met: Back pain measured by the Visual Analog Scale (VAS) or Numeric pain scale at three months (6 – 20 weeks) postoperatively was greater than 3.0 AND Back 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 improvement of less than 5.0 points (G2137)

AND

SUBMISSION CRITERIA 2: BACK PAIN IMPROVEMENT AT ONE YEAR POST LUMBAR FUSION PROCEDURE

‌Denominator (Criteria 2):

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 10/1/2024 to 9/30/2025.

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

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: G9945

Reference Coding:

Denominator Exclusion for cancer, acute fracture or infection OR neuromuscular, idiopathic, or congenital lumbar scoliosis [G9945] may be defined by the following coding, however, other codes/code languages that meet the intent of this component may also be used:

  • Lumbar Spine Region Cancer:
    C41.2, C41.4, C79.51, C79.52, D16.6, D16.8, D48.0, D49.2
  • Acute 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
  • 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
  • Lumbar 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 (Criteria 2):

    All eligible patients whose back 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 VAS or Numeric 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.

    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.

    Copies of the pain scale tools can be obtained at the following link: https://helpdesk.mncm.org/helpdesk/KB/View/17776810-spine-surgery-pro-tools

    Back Pain Target #1 – A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their back pain as less than or equal to 3.0.

    Back Pain Target #2 – A patient who does not meet Back Pain Target #1 is assessed both preoperatively within 3 months prior to the procedure AND postoperatively at one year (9 to 15 months) after the procedure AND the improvement in back 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 G9946 or G2139 is submitted:

    • VAS Pain or Numeric Scale is not administered postoperatively at one year (9 to 15 months)

    • Back pain is measured using a different patient reported tool

    • Postop VAS or Numeric Pain Scale is administered less than nine months or more than 15 months (1 year window)

    • Postoperative VAS or Numeric value is greater than 3.0 and no valid preop to 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: Back 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 Back 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 (G2138)

OR

Performance Not Met: Back pain was not measured by the Visual Analog Scale (VAS) or Numeric pain scale at one year (9 to 15 months) postoperatively (G9946)

OR

Performance Not Met: Back pain measured by the Visual Analog Scale (VAS) or Numeric pain scale at one year (9 to 15 months) postoperatively was greater than 3.0 AND Back 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 improvement of less than 5.0 points (G2139)

RATIONALE

Mechanical low back pain (LBP) remains the second most common symptom-related reason for seeing a physician in the United States. Of the US population, 85% will experience an episode of mechanical LBP at some point during their lifetime. Fortunately, the LBP resolves for the vast majority within 2-4 weeks.
For individuals younger than 45 years, mechanical LBP represents the most common cause of disability and is generally associated with a work-related injury. For individuals older than 45 years, mechanical LBP is the third most common cause of disability, and a careful history and physical examination are vital to evaluation, treatment, and management (Hills et al 2022).

Overall, spine surgery rates have declined slightly from 2002-2007, but the rate of complex fusion procedures increased 15-fold, from 1.3 to 19.9 per 100,000 Medicare beneficiaries. Complications increased with increasing surgical invasiveness, from 2.3% among patients having decompression alone to 5.6% among those having complex fusions. After adjustment for age, comorbidity, previous spine surgery, and other features, the odds ratio (OR) of life-threatening complications for complex fusion compared with decompression alone was 2.95 (95% confidence interval [CI], 2.50- 3.49). A similar pattern was observed for rehospitalization within 30 days, which occurred for 7.8% of patients undergoing decompression and 13.0% having a complex fusion (adjusted OR, 1.94; 95% CI, 1.74-2.17).
Adjusted mean hospital charges for complex fusion procedures were US $80,888 compared with US $23,724 for decompression alone (Deyo, R. JAMA 2010). The MNCM Spine Surgery Measure development workgroup developed patient reported outcome measures for two populations of patients undergoing different lumbar spine procedures, a more complex procedure (lumbar fusion) and a second procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation. In 2018, the development workgroup reconvened and redesigned the measure construct to a target-based measure and additionally expanded the denominator for this measure to include all lumbar discectomy laminectomy procedures.

Rationale for measure construct and calculation change:
Target score based on 2016 study in the Spine Journal Fetke, TF et al “What level of pain are patients happy to live with after surgery for lumbar degenerative disorders?” This study compared the Core Outcomes Measures Index (COMI) and symptom well-being questions to two 0 to 10 graphic ratings scales for back and leg pain. Most spine interventions decrease pain, but rarely do they totally eliminate it. Reporting of the percent of patients achieving a pain score equivalent to the “acceptable symptom state” may represent a more stringent target for denoting surgical success in the treatment of painful spinal disorders. For disc herniation, this is less than or equal to 2, and for other degenerative pathologies it is less than or equal to 3. The OR benchmark of change (5.0) derived from MNCM data (3 years); the average change in points of patients that did achieve the target of less than or equal to 3.0.

Rationale for the expansion of the denominator and addition of exclusions:
During the original development of this measure, the intent was to have a homogeneous population procedure that represented the most common procedure CPT code 63030 for the most common diagnosis of disc herniation. This strategy did not translate well from ICD-9 to ICD-10 diagnosis codes and the volume of eligible denominator patients dropped significantly. In 2018, the MNCM development workgroup reconvened for measure construct redesign and adopted a broader denominator population; all applicable discectomy laminectomy procedure codes and not limited by a type of diagnosis (includes all). With this decision, the workgroup decided to adopt the same exclusions for the spine fusion population and added exclusions for spine related cancer, acute fracture or infection, neuromuscular, idiopathic or congenital scoliosis.

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