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2025 MIPS Measure Back Pain After Lumbar Surgery

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2025 COLLECTION TYPE:

MIPS CLINICAL QUALITY MEASURES (CQMS)

‌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:

This measure is to be submitted each time a patient undergoes a lumbar discectomy/laminectomy or fusion during the denominator identification period. 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.

NOTE: 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.

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) postoperativelyA 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.

    ‌Measure Submission Type:

    Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third-party intermediaries that utilize Medicare Part B claims data. For more information regarding Application Programming Interface (API), please refer to the Quality Payment Program (QPP) website.

    ‌Denominator (Submission 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 1/1/2024 to 12/31/2024.

    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

    WITHOUT

    Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10

    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

    • Patients with a diagnosis of lumbar spine region cancer at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of lumbar spine region cancer: C41.2, C41.4, C79.51, C79.52, D16.6, D16.8, D48.0, D49.2
    • Patients with a diagnosis of acute lumbar spine region fracture at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of 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
    • Patients with a diagnosis of lumbar spine region infection at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of 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
    • Patients with a diagnosis of lumbar neuromuscular, idiopathic, or congenital scoliosis – The following codes would be sufficient to define the Denominator Exclusion (G9945) of 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 (Submission 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)

        ‌Denominator (Submission 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 10/1/2023 to 9/30/2024.

        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

        WITHOUT

        Telehealth Modifier (including but not limited to): GQ, GT, POS 02, POS 10

        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

    • Patients with a diagnosis of lumbar spine region cancer at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of lumbar spine region cancer: C41.2, C41.4, C79.51, C79.52, D16.6, D16.8, D48.0, D49.2
    • Patients with a diagnosis of acute lumbar spine region fracture at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of lumbar spine regionfracture: 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
    • Patients with a diagnosis of lumbar spine region infection at the time of the procedure – The following codes would be sufficient to define the Denominator Exclusion (G9945) of 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
    • Patients with a diagnosis of lumbar neuromuscular, idiopathic, or congenital scoliosis – The following codes would be sufficient to define the Denominator Exclusion (G9945) of 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 (Submission 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)

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