KNEE INJURY FUNCTIONAL IMPROVEMENT

 

Measure ID

IROMS11

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in knee rehabilitation of patients with knee injury measured via their validated Knee Outcome Survey (KOS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of all patients with knee injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.

 

Numerator Description

The total number of patients with knee injuries to not achieve an MCID in their KOS change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

KNEE INJURY NPRS

 

Measure ID

IROMS12

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with knee injury pain.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of all patients with knee injury evaluated and treated by a PT or OT, or PT or OT Group, during the observation window.

 

Numerator Description

The total number of patients with knee injuries to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

HIP, LEG OR ANKLE INJURY FUNCTIONAL IMPROVEMENT

Measure ID

IROMS13

 

Measure Title

Failure to Progress (FTP): Proportion of patients not achieving a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with hip, leg or ankle injuries using the validated Lower Extremity Function Scale (LEFS) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with hip, leg, or ankle injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

 

Numerator Description

The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their LEFS change score (MCID ≥ 9) from their initial visit to their final visit in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

HIP, LEG OR ANKLE INJURY NPRS 

Measure ID

IROMS14

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with hip, leg or ankle (lower extremity except knee) injury.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with hip, leg, or ankle injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

 

Numerator Description

The total number of patients with hip, leg, or ankle injuries hip, leg, or ankle (lower extremity except knee), to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

NECK PAIN/INJURY FUNCTIONAL IMPROVEMENT

Measure ID

IROMS15

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with neck pain/injury measured via the validated Neck Disability Index (NDI).

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of neck pain/injury patients evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

 

Numerator Description

The total number of patients with neck pain/injury to not achieve an MCID in their NDI change score (MCID >10) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

NECK PAIN/INJURY NPRS

Measure ID

IROMS16

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with neck pain/injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

 

Numerator Description

The total number of patients with neck pain/injury to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

LOW BACK PAIN FUNCTIONAL IMPROVEMENT

Measure ID

IROMS17

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation patients with low back pain measured via the validated Modified Low Back Pain Disability Questionnaire (MDQ) score.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with low back pain evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

 

Numerator Description

The total number of patients with low back pain to not achieve an MCID in their MDQ change score (MCID >6) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

LOW BACK PAIN NPRS

Measure ID

IROMS18

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with low back pain.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with low back pain evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

 

Numerator Description

The total number of patients with low back pain to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

ARM, SHOULDER, AND HAND INJURY FUNCTIONAL IMPROVEMENT

Measure ID

IROMS19

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) to indicate functional improvement in rehabilitation of patients with arm, shoulder, and hand injury measured via the validated Disability of Arm Shoulder and Hand (DASH) score, Quick Disability of Arm Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with arm, shoulder, or hand injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group, during the observation window.

 

Numerator Description

The total number of patients with arm, shoulder, or hand injuries to not achieve an MCID in their DASH change score (MCID >10 for DASH, MCID>8 for QDASH) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

ARM, SHOULDER, AND HAND INJURY NPRS

Measure ID

IROMS20

 

Measure Title

Failure to Progress (FTP): Proportion of patients failing to achieve a Minimal Clinically Important Difference (MCID) in in improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.

 

NQS Domain

Effective Clinical Care

 

Measure Type

Patient Reported Outcome

 

Meaningful Measure Area

Functional Outcomes

 

NQF Number

N/A

 

Denominator Description

The total number of patients with arm, shoulder, or hand injury evaluated and treated by a physical therapist (PT) or Occupational Therapist (OT), or PT or OT Group.

 

Numerator Description

The total number of patients with arm, shoulder, and hand injuries to not achieve an MCID in their NPRS change score (MCID >2) from their initial visits to their final visits in PT/OT practice or PT/OT group during the observation window.

 

Denominator Exclusions

Patients who are < 18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that are unable to Read. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO. Patients meeting Medicare requirements for maintenance therapy, such as the maintenance of functional status or prevention of a slow deterioration in function, as defined by the Medicare Benefits Policy Manual, Chapter 15.

 

Denominator Exceptions

PT/OT can use their clinical judgement to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress.

 

Numerator Exclusions

None

 

Measure Risk-Adjusted?

Yes

 

Number of performance rates to be submitted

6

 

High Priority

Yes

 

High Priority Type

Outcome

 

Inverse Measure

Yes

 

Proportional Measure

Yes

 

Continuous Variable Measure

No

 

Ratio Measure

No

 

Care Setting(s)

Outpatient and Telehealth

 

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Updated on 1/4/2021