2026 #471 MIPS Measure Functional Status After Lumbar Surgery

‌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 age 18 and older who had lumbar discectomy/laminectomy or fusion procedure, functional status is rated by the patient as less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) * 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.
* hereafter referred to as ODI

‌Instructions:

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

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) Functional status improvement at three months post lumbar discectomy/laminectomy procedure
OR
2) Functional status 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 functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) at three months (6 to 20 weeks) postoperatively
2) Percentage of lumbar fusion procedures for which the patient reports functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool 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 ODI score that is  less than or equal to 22 OR an improvement of 30 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 functional status 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.

Electronic use of the Oswestry Disability Index (ODI) tool is no longer available free of charge. A paper alternative is available at no cost.

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: FUNCTIONAL STATUS 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 aged ≥ 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: M1466

OR

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 [M1041] 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 functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI version 2.1a) 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 ODI functional status score can be obtained.

Preoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A preoperative ODI functional assessment 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 ODI was obtained, use the ODI that is the most recent and prior to the procedure.

Postoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A postoperative ODI functional assessment score can be obtained from the patient three months (6 to 20 weeks) after the date of procedure. Assessment scores obtained prior to six weeks and after twenty weeks postoperatively will not be used for measure calculation. If more than one postoperative ODI was obtained during the 6 to 20 weeks following the procedure, use the most recent score obtained during the allowable timeframe. ODI can be obtained below or at the following link https://eprovide.mapi-trust.org/instruments/oswestry-disability-index.

Functional Status Target #1 – A patient who is assessed postoperatively at three months (6 to 20 weeks) after the procedure rates their functional status as less than or equal to 22.

Functional Status Target #2 – A patient who does not meet Functional Status 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 is greater than or equal to 30 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 M1049 or G2145 is submitted.

• • ODI is not administered postoperatively at three months (6 to 20 weeks)

  • Functional status is measured using a different patient reported functional status tool or ODI version

  • Postoperative ODI is administered less than 6 weeks or greater than 20 weeks (3 month window)

  • Postoperative ODI is greater than 22 and no valid preoperative ODI to measure improvement

  • Postoperative ODI is greater than 22 and preoperative ODI (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: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at three months (6 – 20 weeks) postoperatively was less than or equal to 22 OR Functional status measured by the ODI version 2.1a within three months preoperatively AND at three months (6 – 20 weeks) postoperatively demonstrated an improvement of 30 points or greater (G2144)

    OR

    Performance Not Met: Functional status was not measured by the Oswestry Disability Index (ODI version 2.1a) at three months (6 – 20 weeks) postoperatively (M1049)

    OR

    Performance Not Met: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at three months (6 – 20 weeks) postoperatively was greater than 22 AND Functional status measured by the ODI version 2.1a within three months preoperatively AND at three months (6 – 20 weeks) postoperatively demonstrated an improvement of less than 30 points (G2145)

    OR

    SUBMISSION CRITERIA 2: FUNCTIONAL STATUS IMPROVEMENT AT ONE YEAR POST LUMBAR FUSION PROCEDURE

    ‌Denominator (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 denominator eligible procedure. This allows for enough time for a follow-up assessment to occur during the twelve month performance period. The denominator identification period includes dates of procedure 10/1/2024 to 9/30/2025.

    Denominator Criteria (Eligible Cases):

    Patients age ≥ 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 EXCLUSION:

    Patient had cancer, acute fracture or infection related to the lumbar spine OR patient had neuromuscular, idiopathic, or congenital lumbar scoliosis: M1041

    Reference Coding:

    Denominator Exclusion for cancer, acute fracture or infection OR neuromuscular, idiopathic, or congenital lumbar scoliosis [M1041] 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 functional status is less than or equal to 22 OR an improvement of 30 points or greater on the Oswestry Disability Index (ODI Version 2.1a) patient reported outcome tool at one year (9 to 15 months) postoperatively

    Definitions:

    Measure Assessment Period (Performance Period) – The period of time following the procedure date that a postoperative Oswestry Disability Index (ODI version 2.1a) functional status score can be obtained.

    Preoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A preoperative ODI functional assessment 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 ODI was obtained, use the ODI that is the most recent and prior to the procedure.

    Postoperative Assessment Oswestry Disability Index (ODI version 2.1a) – A postoperative ODI functional assessment score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained prior to nine months and after fifteen months postoperatively will not be used for measure calculation. If more than one postoperative ODI was obtained during the 9 to 15 months following the procedure, use the most recent score obtained during the allowable timeframe.

    Oswestry Disability Index (ODI version 2.1a) Patient Reported Outcome Tool – An ODI patient reported outcome tool (also known as the Oswestry Low Back Pain Disability Questionnaire) is an extremely important tool that researchers and disability evaluators use to measure a patient’s permanent functional disability. The test is considered the ‘gold standard’ of low back functional outcome tools. A copy of the tool can be obtained below or at the following link: https://eprovide.mapi– trust.org/instruments/oswestry-disability-index

    Functional Status Target #1 – A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their functional status as less than or equal to 22.

    Functional Status Target #2 – A patient who does not meet Functional Status 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 is demonstrated as a decrease in ODI score by greater than or equal to 30 points

    NUMERATOR NOTE: It is recommended that both a preoperative and postoperative assessment tool be administered to the patient to increase the chance 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 M1043 or G2143 is submitted.

    • ODI is not administered postoperatively at one year (9 to 15 months)

    • Functional status is measured using a different patient reported functional status tool or ODI version

    • Postoperative ODI is administered less than 9 months or greater than 15 months (1 year window)

    • Postoperative ODI is greater than 22 and no valid preoperative ODI to measure improvement

    • Postoperative ODI is greater than 22 and preoperative ODI (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: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively was less than or equal to 22 OR Functional status measured by the ODI version 2.1a within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated an improvement of 30 points or greater (G2142)

OR

Performance Not Met: Functional status was not measured by the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively (M1043)

OR

Performance Not Met: Functional status measured by the Oswestry Disability Index (ODI version 2.1a) at one year (9 to 15 months) postoperatively was greater than 22 AND Functional status measured by the ODI version 2.1a within three months preoperatively AND at one year (9 to 15 months) postoperatively demonstrated an improvement of less than 30 points (G2143)

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:
The target was derived from a study “Determination of the Oswestry Disability Index score equivalent to a “satisfactory symptom state” in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registrybased study”. vanHooff, ML et al Spine J. 2016 Oct;16(10):1221-1230. Patient Acceptable Symptom State (PASS), the highest level of symptom beyond which patients consider themselves well. PASS was compared to post-op ODI to determine an equivalent ODI threshold. ODI score less than or equal to 22 indicates the achievement of an acceptable symptom state and can be used as a criterion for treatment success. [AUC]: 0.89 [sensitivity: 78.3%, specificity: 82.1%] for 1 year follow-up]. The OR benchmark of improvement (30) derived from MNCM data (3 years); the average improvement in points of patients that did achieve the target of less than or equal to 22.
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, idiopathic or congenital scoliosis.