2026 #478 MIPS Measure Functional Status Change for Patients with Neck Impairments

2026 COLLECTION TYPE:

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

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

Description:

‌A patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients 14 years+ with neck impairments. The change in FS is assessed using the FOTO Neck FS PROM. The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk-adjusted) and used as a performance measure at the patient, individual clinician, and clinic levels to assess quality.

Instructions:

Reporting Frequency:
This measure is to be submitted a minimum of once per treatment episode for denominator eligible cases as defined in the denominator criteria.

Intent and Clinician Applicability:
The intent of this measure is to assess the change in functional status for patients 14 years and older with a diagnosis of neck impairments or functional deficit affecting the neck. 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 stratum defined by a single submission criteria.
This measure produces a single performance rate.

Implementation Considerations:
For purposes of MIPS implementation, this episode measure is submitted once for each treatment episode during the performance period. It requires submitting the patient’s FS PROM score, at a minimum, at the start (Initial Evaluation or Intake) and again at the conclusion (Discharge) of a Treatment Episode. The Initial Evaluation score is recorded during the first treatment encounter, and the Discharge score is recorded at or near the conclusion of the final treatment encounter.

Definitions:
Functional Deficit – Limitation or impairment of physical abilities/function resulting in evaluation and inclusion in a treatment plan of care.

Treatment Episode – A “Treatment Episode” is defined as beginning with an Initial Evaluation for a functional neck deficit, progressing through treatment without interruption (for example, a hospitalization or surgical intervention), and ending with Discharge signifying that the treatment has been completed. A patient currently under clinical care for a neck deficit remains in a single “Treatment Episode” until the Discharge is conducted and documented by the MIPS eligible clinician.

Initial Evaluation – An “Initial Evaluation” is the first encounter for a functional deficit involving the neck and includes an evaluation (CPT 97161, 97162, 97163, 97165, 97166, 97167, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 98940, 98941, 98942, 98943*, 99304, 99305, or 99306), or an “Initial Evaluation” Status M-code (M1143). A patient presenting with a neck impairment, who has had an interruption of a Treatment Episode for the same functional neck deficit secondary to an appropriate reason like hospitalization or surgical intervention, is an “Initial Evaluation.”

Discharge – “Discharge” is accompanied by a treatment finalization and evaluation completion M-Code (M1009) identifying the close of a Treatment Episode for the same neck deficit identified at the Initial Evaluation and documented by a “Discharge” report by the MIPS eligible clinician. An interruption in clinical care for an appropriate reason like hospitalization or surgical intervention requires a discharge from the current Treatment Episode.

Encounter – A visit between the patient and the provider for the purpose of assessing and/or improving a functional deficit.

Patient Reported – The patient directly provides answers to the FS PROM items. If the patient cannot reliably respond independently (e.g., in the presence of cognitive deficits), a suitable proxy may provide answers.

Risk Adjustment Factors – A set of factors used to calculate a patient’s risk score which predict the outcome score. In addition to the risk adjustment factors collected in the patient demographic portion of the assessment, a full list of considered specific comorbidity details can be found in Table 1 of this publication https://www.ncbi.nlm.nih.gov/pubmed/29787696 7.

Neck FS PROM score – The “Neck FS PROM score” may be achieved using one of three forms: the FOTO Neck FS PROM computer adaptive test, the FOTO Neck FS PROM short form, or an alternative PROM score that is cross-walked to the Neck FS PROM using a cross-walk form developed by the measure steward. Computer adaptive test (CAT) is recommended to achieve best balance between reduced patient burden and score precision. At least one cross-walk form has been developed by the measure steward and meets scientific standards to successfully link a construct-equivalent PROM using advanced psychometric equating methods.

For more information about the Neck FS PROM score forms and to access the components that are available free of charge for use with this MIPS quality measure [e.g., patient-reported outcome measure(s), cross-walking, risk adjustment], visit Public Access to FOTO Measures.

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 14 years and older with neck impairments who initiated a Treatment Episode

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 aged >14 years on date of Initial Evaluation

AND

Patient encounter during the performance period identifying evaluation (CPT or M-code): 97161, 97162, 97163, 97165, 97166, 97167, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 98940, 98941, 98942, 98943*, 99304, 99305, 99306, M1143, M1426

AND

With a neck impairment and/or diagnosis pertaining to a functional deficit affecting the neck at time of initial evaluation (ICD-10-CM): G54.0, G54.2, M40.03, M40.12, M40.13, M40.202, M40.203, M41.122, M41.123, M41.22, M41.23, M41.41, M41.42, M41.43, M41.52, M41.53, M41.82, M41.83, M42.01, M42.02, M42.03, M42.11, M42.12, M42.13, M43.01, M43.02, M43.03, M43.11, M43.12, M43.13, M43.21, M43.22, M43.23, M43.3, M43.4, M43.5X2, M43.5X3, M43.6, M43.8X1, M43.8X2, M43.8X3, M45.A1, M45.A2, M45.A3, M45.1, M45.2, M45.3, M46.01, M46.02, M46.03, M46.21, M46.22, M46.23, M46.31, M46.32, M46.33, M46.41, M46.42, M46.43, M46.51, M46.52, M46.53, M46.81, M46.82, M46.83, M46.91, M46.92, M46.93, M47.11, M47.12, M47.13, M47.21, M47.22, M47.23, M47.811, M47.812, M47.813, M47.891, M47.892, M47.893, M48.01, M48.02, M48.03, M48.11, M48.12, M48.13, M48.21, M48.22, M48.23, M48.31, M48.32, M48.33, M48.41XD, M48.41XG, M48.41XS, M48.42XD, M48.42XG, M48.42XS, M48.43XD, M48.43XG, M48.43XS, M48.51XD, M48.51XG, M48.51XS, M48.52XD, M48.52XG, M48.52XS, M48.53XD, M48.53XG, M48.53XS, M48.8X1, M48.8X2, M48.8X3, M49.81, M49.82, M49.83, M50.01, M50.020, M50.021, M50.022, M50.023, M50.03, M50.11, M50.120, M50.121, M50.122, M50.123, M50.13, M50.21, M50.220, M50.221, M50.222, M50.223, M50.23, M50.31, M50.320, M50.321, M50.322, M50.323, M50.33, M50.81, M50.820, M50.821, M50.822, M50.823, M50.83, M50.91, M50.920, M50.921, M50.922, M50.923, M50.93, M53.0, M53.1, M53.2X1, M53.2X2, M53.2X3, M53.81, M53.82, M53.83, M54.11, M54.12, M54.13, M54.2, M54.01, M54.02, M54.03, M95.3, M99.01, M99.11, M99.21, M99.31, M99.41, M99.51, M99.61, M99.71, M99.81, P14.3, Q76.1, Q76.411, Q76.412, Q76.413, Q76.5, S12.000D, S12.000G, S12.000K, S12.000S, S12.001D, S12.001G, S12.001K, S12.001S, S12.01XD, S12.01XG, S12.01XK, S12.01XS, S12.02XD, S12.02XG, S12.02XK, S12.02XS, S12.030D, S12.030G, S12.030K, S12.030S, S12.031D, S12.031G, S12.031K, S12.031S, S12.040D, S12.040G, S12.040K, S12.040S, S12.041D, S12.041G, S12.041K, S12.041S, S12.090D, S12.090G, S12.090K, S12.090S, S12.091D, S12.091G, S12.091K, S12.091S, S12.100D, S12.100G, S12.100K, S12.100S, S12.101D, S12.101G, S12.101K, S12.101S, S12.110D, S12.110G, S12.110K, S12.110S, S12.111D, S12.111G, S12.111K, S12.111S, S12.112D, S12.112G, S12.112K, S12.112S, S12.120D, S12.120G, S12.120K, S12.120S, S12.121D, S12.121G, S12.121K, S12.121S, S12.130D, S12.130G, S12.130K, S12.130S, S12.131D, S12.131G, S12.131K, S12.131S, S12.14XD, S12.14XG, S12.14XK, S12.14XS, S12.150A, S12.150B, S12.150D, S12.150G, S12.150K, S12.150S, S12.151D, S12.151G, S12.151K, S12.151S, S12.190D, S12.190G, S12.190K, S12.190S, S12.191D, S12.191G, S12.191K, S12.191S, S12.200D, S12.200G, S12.200K, S12.200S, S12.201D, S12.201G, S12.201K, S12.201S, S12.230D, S12.230G, S12.230K, S12.230S, S12.231D, S12.231G, S12.231K, S12.231S, S12.24XD, S12.24XG, S12.24XK, S12.24XS, S12.250D, S12.250G, S12.250K, S12.250S, S12.251D, S12.251G, S12.251K, S12.251S, S12.290D, S12.290G, S12.290K, S12.290S, S12.291D, S12.291G, S12.291K, S12.291S, S12.300D, S12.300G, S12.300K, S12.300S, S12.301D, S12.301G, S12.301K, S12.301S, S12.330D, S12.330G, S12.330K, S12.330S, S12.331D, S12.331G, S12.331K, S12.331S, S12.34XD, S12.34XG, S12.34XK, S12.34XS, S12.350D, S12.350G, S12.350K, S12.350S, S12.351D, S12.351G, S12.351K, S12.351S, S12.390D, S12.390G, S12.390K, S12.390S, S12.391D, S12.391G, S12.391K, S12.391S, S12.400D, S12.400G, S12.400K, S12.400S, S12.401D, S12.401G, S12.401K, S12.401S, S12.430D, S12.430G, S12.430K, S12.430S, S12.431D, S12.431G, S12.431K, S12.431S, S12.44XD, S12.44XG, S12.44XK, S12.44XS, S12.450D, S12.450G, S12.450K, S12.450S, S12.451D, S12.451G, S12.451K, S12.451S, S12.490D, S12.490G, S12.490K, S12.490S, S12.491D, S12.491G, S12.491K, S12.491S, S12.500D, S12.500G, S12.500K, S12.500S, S12.501D, S12.501G, S12.501K, S12.501S, S12.530D, S12.530G, S12.530K, S12.530S, S12.531D, S12.531G, S12.531K, S12.531S, S12.54XD, S12.54XG, S12.54XK, S12.54XS, S12.550D, S12.550G, S12.550K, S12.550S, S12.551D, S12.551G, S12.551K, S12.551S, S12.590D, S12.590G, S12.590K, S12.590S, S12.591D, S12.591G, S12.591K, S12.591S, S12.600D, S12.600G, S12.600K, S12.600S, S12.601D, S12.601G, S12.601K, S12.601S, S12.630D, S12.630G, S12.630K, S12.630S, S12.631D, S12.631G, S12.631K, S12.631S, S12.64XD, S12.64XG, S12.64XK, S12.64XS, S12.650D, S12.650G, S12.650K, S12.650S, S12.651D, S12.651G, S12.651K, S12.651S, S12.690D, S12.690G, S12.690K, S12.690S, S12.691D, S12.691G, S12.691K, S12.691S, S12.8XXD, S12.8XXS, S12.9XXD, S12.9XXS, S13.0XXD, S13.0XXS, S13.100D, S13.100S, S13.101D, S13.101S, S13.110D, S13.110S, S13.111D, S13.111S, S13.120D, S13.120S, S13.121D, S13.121S, S13.130D, S13.130S, S13.131D, S13.131S, S13.140D, S13.140S, S13.141D, S13.141S, S13.150D, S13.150S, S13.151D, S13.151S, S13.160D, S13.160S, S13.161D, S13.161S, S13.170D, S13.170S, S13.171D, S13.171S, S13.180D, S13.180S, S13.181D, S13.181S, S13.29XD, S13.29XS, S13.4XXA, S13.4XXD, S13.4XXS, S13.5XXA, S13.5XXD, S13.5XXS, S13.8XXA, S13.8XXD, S13.8XXS, S14.0XXD, S14.0XXS, S14.2XXD, S14.2XXS, S14.3XXD, S14.3XXS, S14.4XXD, S14.4XXS, S14.5XXD, S14.5XXS, S14.8XXD, S14.8XXS, S14.9XXD, S14.9XXS, S16.1XXA, S16.1XXD, S16.1XXS, S16.2XXA, S16.2XXD, S16.2XXS, S16.8XXA, S16.8XXD, S16.8XXS, S16.9XXA, S16.9XXD, S16.9XXS, S17.8XXA, S17.8XXD, S17.8XXS, S19.89XA, S19.89XD, S19.89XS, S19.9XXA, S19.9XXD, S19.9XXS

AND

Discharge/discontinuation of the episode of care documented in the medical record (M-code): M1009

AND NOT

DENOMINATOR EXCLUSIONS:

Documentation stating patient has a diagnosis of a degenerative neurological condition such as ALS, MS, or Parkinson’s diagnosed at any time before or during the episode of care: G2151

OR

‌Patient unable to complete the Neck FS PROM at Initial Evaluation and/or Discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility, and an adequate proxy is not available: M1149

NUMERATOR:

Patients who were presented with the Neck FS PROM at Initial Evaluation (Intake) and at or near Discharge (Status) for the purpose of calculating the patient’s Residual Score

Definitions:

Functional Status (FS) Score – This is the Neck FS PROM score as described under Instructions Definitions. FS Change Score – The “FS Change Score” is calculated by subtracting the FS Score at Initial Evaluation from the FS Score at Discharge.

Predicted FS Change Score – The “Predicted FS Change Score” is calculated by accounting for the influence of multiple patient characteristics as designated by the risk adjustment model. For each patient completing the Neck FS PROM at Initial Evaluation (Intake), the predictive model provides a risk-adjusted prediction of FS change at Discharge.

Residual Score – The “Residual Score” is calculated by subtracting the Predicted FS Change Score from the FS Change Score (i.e., actual minus predicted). The “Residual Score”, which is in the same units as the FS Score, should be interpreted as the amount of FS change that is different than the amount of change that was predicted given the risk-adjustment variables of the patient being treated. Residual Scores of zero (0) or greater (> 0) should be interpreted as FS Change Scores that met or exceeded what was predicted. Residual Scores less than zero (< 0) should be interpreted as FS change scores that were less than predicted. Aggregated Residual Scores allow meaningful comparisons amongst clinicians or clinics.

Numerator Options:

Performance Met: Residual Score for the neck impairment successfully calculated and the score was equal to zero (0) or greater than zero (> 0) (G2152)

OR

Denominator Exception: Ongoing care not clinically indicated because the patient needed a home program only, referral to another provider or facility, or consultation only, as documented in the medical record (M1146)

OR

Denominator Exception: Ongoing care not medically possible because the patient was discharged early due to specific medical events, documented in the medical record, such as the patient became hospitalized or scheduled for surgery (M1147)

OR

Denominator Exception: Ongoing care not possible because the patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown) (M1148)

OR

Denominator Exception: Patient refused to participate (G2209)

OR

Performance Not Met: Residual Score for the neck impairment successfully calculated and the score was less than zero (< 0) (G2167)

OR

Performance Not Met: Residual Score for the neck impairment not measured because the patient did not complete the Neck FS PROM at Initial Evaluation and/or near Discharge, reason not given (G2210)

RATIONALE

Neck impairments provide a common reason for patients seeking care in healthcare settings. During 2017, the FOTO database recorded 414,436 episodes of care across multiple healthcare systems and clinics throughout the United States. Prevalence estimates from epidemiologic studies on neck pain (defined as pain in the neck, with or without pain referred into one or both upper limbs, that lasts for at least 1 day) have a mean 1-year prevalence range of 23%1 to 37% and a mean lifetime prevalence of 49%.2 Consequently, neck pain is recognized as a global health care burden.3,4 Assessment of functional status using PROMs in patients with neck pain is an essential step in addressing this burden, provided the scores can be interpreted in clinically useful ways to inform patient-centered clinical decision making. 5, 6
The Neck FS PROM offers the advantages of modern scientific measurement methods like item response theory (IRT). IRT and related methods provide a number of measurement advantages including valid assumptions of interval scaling, superior scale coverage, uni-dimensionality for valid score change interpretations, and precise methods for evaluating components of the measures such as the functional questions and scales. IRT additionally forms the basis for computer adaptive testing (CAT) administration which reduces patient burden by minimizing the number of functional questions the patient must respond to in order to obtain a precise estimate of the patient’s functional ability level. When combined with robust risk adjustment to provide for fair comparisons between providers, the Neck FS PROM forms the basis for a valuable patient reported outcome performance measure (PRO-PM).