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.

Measure Description

The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level.

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 greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO

Patients that have a life expectancy of 6 months or less

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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Home Care; Outpatient Services; Post-Acute Care; Ambulatory Surgical Center.

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.

Measure Description

The proportion of patients failing to achieve MCID of two (2) points or more improvement in the NPRS change score for patients with knee injuries treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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 greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO

Patients that have a life expectancy of 6 months or less

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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another

provider or facility, consultation only, or discharged due to significant decline in medical status as

documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are

extremely medically complex, who in their experience are likely to make poor clinical progress. The provider

must clearly document in the medical record the specific medical complexity / complexities present to qualify

for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Home Care; Outpatient Services; Post-Acute Care; Ambulatory Surgical Center.

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.

Measure Description

The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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, during the observation window.

Numerator Description

The total number of patients with hip, leg, or ankle injuries to not achieve an MCID in their LEFS change score (MCID greater than9) 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

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.

Measure Description

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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, during the observation window.

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 greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

NECK PAIN/INJURY FUNCTIONAL IMPROVEMENT

Measure ID

KEET01*

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).

Measure Description

The proportion of patients failing to achieve an MCID of seven and a half (7.5) points or more improvement in the NDI change score for neck pain/injury patients treated during the observation period will be reported.

Additionally, a risk-adjusted NDI change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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 neck pain/injury to not achieve an MCID in their NDI change score (MCID greater than or equal to 7.5) 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.<

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

*KEET01 mirrors the historical IROMS15 quality measure except for the MCID which is set at 7.5 to reflect the most recent evidence based research.

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 improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with neck pain/injury.

Measure Description

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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, during the observation window.

Numerator Description

The total number of patients with neck pain/injury to not achieve an MCID in their NPRS change score (MCID greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS PRO

Patients that have a life expectancy of 6 months or less

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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another

provider or facility, consultation only, or discharged due to significant decline in medical status as

documented in the medical record). 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. The provider

must clearly document in the medical record the specific medical complexity / complexities present to qualify

for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

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.

Measure Description

The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description

The total number of all patients with low back 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 low back pain to not achieve an MCID in their MDQ change score (MCID greater than or equal to 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 less than18 years old. Patients who did not complete 2 or more surveys. Patients that are non-English speaking and translation services are unavailable. Patients that have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

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.

Measure Description

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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 NPRS change score (MCID greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

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.

Measure Description

The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder, and hand injury patients treated during the observation period will be reported.

Additionally, a risk-adjusted MCID change proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical and occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

Denominator Description

The total number of all patients with arm, shoulder, or hand 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 arm, shoulder, or hand injuries to not achieve an MCID in their DASH change score (MCID greater than or equal to 10 for DASH, MCID greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

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 improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation patients with arm, shoulder, or hand injury.

Measure Description

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported.

Additionally, a risk-adjusted MCID proportional difference will be determined by calculating the difference between the risk model predicted and observed MCID proportion will be reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit).

These measures will serve as a physical or occupational therapy performance measure at the eligible physical or occupational therapist or physical or occupational therapy group level.

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, and hand injuries to not achieve an MCID in their NPRS change score (MCID greater than or equal to 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 less than 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). PT/OT can use their clinical judgment to exclude patients who are extremely medically complex, who in their experience are likely to make poor clinical progress. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception.

Numerator Exclusions

None

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient-Reported Outcome-based Performance Measure (PRO-PM)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

Yes

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

6

Measure Risk-Adjusted?

Yes

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-Acute Care; Outpatient Services

DIZZINESS HANDICAP INVENTORY

Measure ID

HM7

Measure Title

Functional Status Change for Patients with Vestibular Dysfunction

Measure Description

Percentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) as measured via the validated Dizziness Handicap Inventory or equivalent instrument to indicate functional, emotional, and physical improvement

• Submission Age Criteria 1: Patients aged 14-17 years of age
• Submission Age Criteria 2: Patients aged 18-64 years of age
• Submission Age Criteria 3: Patients aged 65 years and older
• Submission Criteria 4: Overall total rate of patients aged 14 years and older

The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.

Denominator Description

Denominator Criteria (Eligible Cases):

SUBMISSION CRITERIA 1: Patients aged 14-17 years of age on date of encounter

SUBMISSION CRITERIA 2: Patients aged 18-64 years and older on date of encounter

SUBMISSION CRITERIA 3: Patients aged 65 years of age and older on date of encounter

SUBMISSION CRITERIA 4: Patients aged 14 years of age and older on date of encounter

AND

A diagnosis of vestibular dysfunction diagnosis (ICD-10-CM): BPPV: H81.10, H81.11, H81.12, H81.13

OR

Dizziness: R42, H81.10, H81.11, H81.12, H81.13,

OR

Disorders of vestibular function: H81*

OR

Vertiginous syndromes: H82*

OR

Other diseases of inner ear: H83*

OR

Abnormalities of gait and mobility: R26*

OR

Other lack of coordination: R27*

OR

Repeated falls: R29.6

OR

Concussion: S06.0*, F07.81

OR

History of falling: Z91.81

OR

Epidemic vertigo: A88.1

OR

Benign neoplasm of cranial nerves: D33.3

OR

Migraine: B43.109, G43.819

AND

An Index Patient Visit Indicator:

Physical Therapy CPT: 97161, 97162, 97163

OR

Occupational Therapy CPT: 97165, 97166, 97167

AND

Two face to face patient encounters for a treatment episode that began or ended during the performance period: GXXXX[DB1]

Numerator Description

Patients who achieved a MCID in vestibular dysfunction, as measured via the validated Dizziness Handicap Inventory or equivalent instrument, to indicate functional improvement greater than zero and a Risk Adjusted Functional Status Change Residual Score for the dizziness handicap successfully calculated with an MCID score that is greater than zero from their initial visits and just prior to or at their discharge visits from the PT/OT practice

Denominator Exclusions

Hospice services received by patient at any time during the performance period: GXXXX

OR

Patient unable to complete a DHI or equivalent instrument at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility without the availability of an adequate proxy available: GXXXX

Denominator Exceptions

N/A

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Outcome

Meaningful Measure Area

Functional Outcomes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

4

Measure Risk-Adjusted?

No

Care Setting(s)

Ambulatory Care: Clinician Office/Clinic

 

* 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

 

HM7 | This measure is owned by MIPSPro Enterprise Qualified Clinical Data Registry and managed by Keet Outcomes, the Qualified Clinical Data Registry of Keet, Inc. For permissions contact, QCDR@KeetHealth.com

 

2023 QPP Keet QCDR Improvement Activities

IA_AHE_3-High- Promote Use of Patient-Reported Outcome Tools

IA_BE_6-High_ Regularly Assess Patient Experience of Care and Follow Up on Findings

IA_BE_14-High- Engage Patients and Families to Guide Improvement in the System of Care

Improved Practices that Engage Patients Pre-Visit

IA_BE_22-Medium- Improved Practices that Engage Patients Pre-Visit

IA_PSPA_7 -Medium-Use of QCDR Data for ongoing Practice Assessment and Improvements

 

Note: Below were removed as measures for 2023 PY:

IA_BE_8 Participation in a QCDR, that promotes collaborative learning network opportunities that are interactive.

IA_BE_7 Participation in a QCDR, that promotes use of patient engagement tools.

 

Hoping to print these out for use in your clinic? Download a printable list of our measures here.

 

Updated on 6/12/2023

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 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. 

Measure Description 

The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the KOS change score for patients with knee injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, 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 of patients with knee injury. 

Measure Description 

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with knee injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline KOS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, Outpatient and Telehealth 

 

HIP, LEG OR ANKLE INJURY FUNCTIONAL IMPROVEMENT 

Measure ID 

IROMS13 

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 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. 

Measure Description 

The proportion of patients failing to achieve an MCID of nine (9) points or more improvement in the LEFS change score for patients with hip, leg, or ankle injuries treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with hip, leg, or ankle 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 hip, leg, or ankle injuries to not achieve an MCID in their LEFS change score (MCID ≥ 9) 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, 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 of patients with hip, leg, or ankle (lower extremity except knee) injury. 

Measure Description 

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with hip, leg, or ankle injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline LEFS score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with hip, leg, or ankle 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 hip, leg, or ankle (lower extremity except 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, Outpatient and Telehealth 

 

NECK PAIN/INJURY FUNCTIONAL IMPROVEMENT 

Measure ID 

KEET01* 

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 their validated Neck Disability Index (NDI) score. 

Measure Description 

The proportion of patients failing to achieve an MCID of seven and ½ (7.5) points or more improvement in the NDI change score for patients with neck pain/injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

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 injuries to not achieve an MCID in their NDI change score (MCID ≥7.5) 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, Outpatient and Telehealth 

*KEET01 mirrors the historical IROMS15 quality measure except for the MCID which is set at 7.5 to reflect the most recent evidence based research. 

 

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 improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation of patients with neck pain/injury. 

Measure Description 

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with neck pain/injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline NDI score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with neck pain/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 neck pain/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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, 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 of patients with low back pain measured via their validated Modified Low Back Pain Disability Questionnaire (MDQ) score. 

Measure Description 

The proportion of patients failing to achieve an MCID of six (6) points or more improvement in the MDQ change score for patients with low back pain treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with low back 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 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, 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 of patients with low back pain. 

Measure Description 

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with low back pain treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline MDQ score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with low back pain 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 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, 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, or hand injury measured via their validated Disability of the Arm, Shoulder and Hand (DASH) score, Quick Disability of the Arm, Shoulder and Hand (QDASH) score, or equivalent instrument which has undergone peer reviewed published validation and demonstrates a peer reviewed published MCID. 

Measure Description 

The proportion of patients failing to achieve an MCID of ten (10) points or more improvement in the DASH change score or eight (8) points or more improvement in the QDASH change score for patients with arm, shoulder or hand injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH or QDASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with arm, shoulder, or hand 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 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, 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 improvement in pain score, measured via the Numeric Pain Rating Scale (NPRS), in rehabilitation of patients with arm, shoulder, or hand injury. 

Measure Description 

The proportion of patients failing to achieve an MCID of two (2) points or more improvement in the NPRS change score for patients with arm, shoulder, or hand injury treated during the observation period will be reported. 

Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference between the risk model predicted and observed MCID proportion will reported for each physical therapist or physical therapy group. The risk adjustment will be calculated using a logistic regression model using: baseline DASH score, baseline pain score, age, sex, payer, and symptom duration (time from surgery or injury to baseline physical therapy visit). 

These measures will serve as a PT/OT performance measure at the eligible PT/OT or PT/OT group level. 

Denominator Description 

The total number of all patients with arm, shoulder, or hand 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 arm, shoulder, or 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 have a mental or cognitive impairment that compromises their ability accurately complete the MIPS patient reported outcome (PRO). Patients that have a life expectancy of 6 months or less. 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 

Ongoing care not indicated, patient seen only 1-2 visits (e.g., home program only, referred to another provider or facility, consultation only, or discharged due to significant decline in medical status as documented in the medical record). 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. The provider must clearly document in the medical record the specific medical complexity / complexities present to qualify for this exception. 

Numerator Exclusions 

None 

NQF Number 

N/A 

NQS Domain 

Effective Clinical Care 

Includes Telehealth

Yes

High Priority Measure 

Yes 

High Priority Type 

Outcome 

Measure Type 

Patient Reported Outcome 

Meaningful Measure Area 

Functional Outcomes 

Inverse Measure 

Yes 

Proportional Measure 

Yes 

Continuous Variable Measure 

No 

Ratio Measure 

No 

Number of performance rates to be submitted 

6 

Measure Risk-Adjusted? 

Yes 

Care Setting(s) 

Ambulatory Care, Clinician Office / Clinic, Outpatient and Telehealth 

 

FUNCTIONAL STATUS CHANGE FOR PATIENTS WITH VESTIBULAR DYSFUNCTION, (DIZZINESS HANDICAP INVENTORY)

Measure ID

HM7

Measure Title

Functional Status Change for Patients with Vestibular Dysfunction.

Measure Description

Percentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) to indicate functional, emotional, and physical improvement.

• Submission Age Criteria 1: Patients aged 14-17 years of age
• Submission Age Criteria 2: Patients aged 18-64 years of age
• Submission Age Criteria 3: Patients aged 65 years and older
• Submission Criteria 4: Overall total rate of patients aged 14 years and older
• Submission Risk Adjusted Criteria 5: Overall total rate of patients aged 14 and older.

The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.

Denominator Description

Denominator Criteria (Eligible Cases):

SUBMISSION CRITERIA 1: Patients aged 14-17 years of age on date of encounter
SUBMISSION CRITERIA 2: Patients aged 18-64 years and older on date of encounter
SUBMISSION CRITERIA 3: Patients aged 65 years of age and older on date of encounter
SUBMISSION CRITERIA 4: Patients aged 14 years of age and older on date of encounter
AND

A diagnosis of vestibular dysfunction diagnosis (ICD-10-CM): BPPV: H81.10, H81.11, H81.12, H81.
OR
Dizziness: R42, H81.10, H81.11, H81.12, H81.13,
OR
Disorders of vestibular function: H81*
OR
Vertiginous syndromes: H82*
OR
Other diseases of inner ear: H83*
OR
Abnormalities of gait and mobility: R26*

OR
Other lack of coordination: R27*

OR
Repeated falls: R29.6
OR
Concussion: S06.0*, F07.81
OR
History of falling: Z91.81
OR
Epidemic vertigo: A88.1
OR
Benign neoplasm of cranial nerves: D33.3
OR
Migraine: B43.109, G43.819

AND

An Index Patient Visit Indicator:
Physical Therapy CPT: 97161, 97162, 97163
OR
Occupational Therapy CPT: 97165, 97166, 97167

AND

Two face to face patient encounters for a treatment episode that began or ended during the performance period.

Numerator Description

Patients who achieved a MCID in vestibular dysfunction, as measured via the validated Dizziness Handicap Inventory or equivalent instrument, to indicate functional improvement greater than zero and a Risk Adjusted Functional Status Change Residual Score for the dizziness handicap successfully calculated with an MCID score that is greater than zero from their initial visits and just prior to or at their discharge visits from the PT/OT practice.

Denominator Exclusions

Hospice services received by patient at any time during the performance period OR Patient unable to complete a DHI or equivalent instrument at admission and discharge due to blindness, illiteracy, severe mental incapacity or language incompatibility without the availability of an adequate proxy available.

Denominator Exceptions

N/A

NQF Number

N/A

NQS Domain

Effective Clinical Care

Includes Telehealth

Yes

High Priority Measure

Yes

High Priority Type

Outcome

Measure Type

Patient Reported Outcome

Meaningful Measure Area

Functional Outcomes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

4

Measure Risk-Adjusted?  

Yes

Care Setting(s)

Ambulatory Care, Clinician Office / Clinic

 

Hoping to print these out for use in your clinic? Download a printable list of our measures here. 

 

Updated on 2/2/2022