2018 MIPS Measure #460: Average Change in Back Pain following Lumbar Fusion

Measure Type	High Priority Measure?	NQS Domain
Outcome	Yes	Person and Caregiver-Centered Experience and Outcomes
Data Submission Method(s)
Registry

Measure Description

The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion procedure

Instructions

This measure is to be submitted each time a patient undergoes a lumbar fusion during the denominator identification period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. Unique to this measure is the additional Minimum Process of Care Performance Threshold Requirement that at least 50% of the denominator eligible patients must have a preoperative and postoperative pain assessment, therefore if the performance rate for the measure is below 50%, the eligible clinician would not be able to meet the denominator of the second submission criteria therefore this measure CANNOT BE SUBMITTED. CMS anticipates that the sum of change for the second submission criteria will be calculated using 100% of all procedures that meet performance in the first submission criteria.

NOTE: This measure contains elements of a proportion or rate and a simple average of the change in back pain preoperatively to postoperatively among patients having received a lumbar fusion procedure.

There are two criteria required to submit this measure per program requirements. There is the standard program requirement of Data Completeness for all denominator eligible procedures (those receiving lumbar spine fusion procedure) must be submitted. Unique to this measure there is the additional requirement of a Minimum Process of Care Threshold Requirement that at least 50% of all denominator eligible procedures must have a preoperative and postoperative pain assessment. A preoperative and postoperative pain assessment using the Visual Analog Scale (VAS) within three months preoperatively AND at one year (+/- 3 months) postoperatively for at least 50% of denominator eligible patients receiving a lumbar fusion is a denominator inclusion criterion to be eligible to submit this performance measure – the average change in preoperative to postoperative pain level (submission criteria 2). An eligible clinician must submit 100% of the population identified with a preoperative and postoperative pain assessment (Performance Met Criteria for Submission Criteria One) of this measure for Submission Criteria Two. It is anticipated that eligible clinicians who perform the listed procedures as specified in the denominator coding should therefore assess both preoperative and postoperative pain AND therefore may submit this measure.

Example:

Eligible Clinician A and B both perform 200 lumbar fusion procedures. While to meet the program requirements for Data Completeness at least 100 procedures must be submitted, the measure intent is that all denominator eligible procedures will be submitted to calculate the Performance Met criterion for Submission Criteria One. Of all the denominator eligible procedures– at least 100 (50%) must have both a preoperative and postoperative patient reported pain assessments using the Visual Analog Scale (VAS). If at least 50% of the submitted procedures do not have the required preoperative and postoperative pain assessment, then this measure cannot be submitted.

Eligible Clinician A has 111 procedures with both a preoperative and postoperative patient reported pain assessment. Eligible Clinician A would submit performance for all 200 procedures of which the 111 procedures equal a Performance Met Performance Rate of 55.5% for Submission Criteria One.

Eligible Clinician A’s rate of 55.5% meets the Submission Criteria Two Minimum Process of Care Performance Threshold Requirement for submitting average change in pain, and therefore Eligible Clinician A would submit the average change (preoperative to one year postoperative) in back pain for the 111 procedures for Submission Criteria Two.

Eligible Clinician B has 95 procedures with both a preoperative and postoperative patient reported pain assessment. If Eligible Clinician B would submit performance for all 200 procedures of which the 95 procedures would equal a Performance Met Performance Rate of 47.5% for Submission Criteria One.

Eligible Clinician B’s performance rate is less than 50% which does not meet the Submission Criteria Two Minimum Process of Care Performance Threshold Requirement for submitting average change in pain. Therefore even though the program requirement of Data Completeness with 50% of denominator eligible procedures has been met, Eligible Clinician B would be unable to submit performance for this measure as the Minimum Process of Care Threshold Requirement for Submission Criteria Two was not met as only 47.5% of all denominator eligible procedures have a both a preoperative and postoperative patient reported pain assessment.

The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

Measure Submission:

Denominator

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

Percentage of patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar spine fusion procedure performed during the denominator identification period and whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (+/- 3 months) postoperatively.

Average of the change in pain preoperatively to post-operatively among patients having received a lumbar fusion.

SUBMISSION CRITERIA 1: PATIENTS 18 YEARS OF AGE OR OLDER AS OF JANUARY 1 OF THE DENOMINATOR IDENTIFICATION PERIOD WHO HAD A LUMBAR SPINE FUSION PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD

DENOMINATOR (SUBMISSION CRITERIA 1):

Patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar spine fusion procedure performed during the denominator identification period

Definition:

Denominator Identification Period – The twelve month period in which eligible patients have a procedure. This allows for enough time for a follow-up assessment to occur during the performance period. The denominator identification period includes dates of procedure 10/1/2016 to 9/30/2017.

October 1 of the Denominator Identification Period

AND

Patient procedure during performance period (CPT): 22533, 22534, 22558, 22586, 22612, 22630, 22633

AND NOT

DENOMINATOR EXCLUSION:

Patient had cancer, fracture or infection related to the lumbar spine OR patient had idiopathic or congenital scoliosis: G9945

–OR–

SUBMISSION CRITERIA 2: AVERAGE CHANGE (PREOPERATIVE TO ONE YEAR POSTOPERATIVE) IN BACK PAIN FOR ALL ELIGIBLE PATIENTS 18 YEARS OF AGE OR OLDER AS OF OCTOBER 1 OF THE DENOMINATOR IDENTIFICATION PERIOD WHO HAD A LUMBAR SPINE FUSION PROCEDURE PERFORMED DURING THE DENOMINATOR IDENTIFICATION PERIOD AND WHOSE BACK PAIN WAS MEASURED BY THE VISUAL ANALOG SCALE (VAS) WITHIN THREE MONTHS PREOPERATIVELY AND AT ONE YEAR (+/- 3 MONTHS) POSTOPERATIVELY

DENOMINATOR (SUBMISSION CRITERIA 2):

Patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar spine fusion procedure performed during the denominator identification period and whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (+/- 3 months) postoperatively

Definition:

Measure Assessment Period (Performance Period) – The period of time following the procedure date that is in which a postoperative VAS pain scale score is obtained.

Minimum Process of Care Threshold Requirement -Eligible clinician must have at least 50% of all eligible patients receiving lumbar fusion procedure that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 1 year (9 to 15 months) postoperatively. An eligible clinician must submit 100% of the population identified within the Performance Met Criteria for Submission Criteria One of this measure in order to calculate the average rate of change for Submission Criteria Two of this measure.

Preoperative Assessment VAS Pain – A preoperative VAS pain scale score can be obtained from the patient any time up to three months preoperatively, inclusive of the date of the procedure. Assessment scores obtained more than three months before the procedure will not be used for measure calculation.

Postoperative Assessment VAS Pain -A postoperative VAS pain scale score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained prior to nine months and after 15 months postoperatively will not be used for measure calculation.

Visual Analog Scale (VAS) – A visual analog scale is a continuous line indicating the continuum between two states of being. A copy of the tool can be obtained at Visual Analog Scale Tool

Visual Analog Pain Scale

Back Pain:

How severe is your back pain today?

Please place an “X” in a box below the line to indicate how bad you feel your back pain is today. Please select (“X”) only ONE box.

No Pain

________________________________________________________

Intolerable

The tool must contain the end points of “No Pain” and “Intolerable”. The tool must not display the actual numbers to the patient. It is not acceptable to substitute a numeric rating scale (e.g.; to ask the patient on a scale of one to 10 what number would you use to rate your pain).

Below is the key for eligible clinicians to utilize in order to convert patient’s “X” to a number for measuring change. Do not use this scale for patient completion. The corresponding numeric value is used for measurement of improvement. The numeric equivalent has 21 possible points from 0 to ten with 0.5 intervals (e.g.; 0, 0.5, 1.0, 1.5, 2.0, 2.5, 3.0).

No Pain

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

Intolerable

Denominator Criteria (Eligible Cases) 2:

Minimum Process of Care Threshold Requirement : Eligible clinician has at least 50% of all eligible patients receiving lumbar fusion procedure that have back pain measured with the Visual Analog Scale (VAS) within 3 months preoperatively AND at 1 year (9 to 15 months) postoperatively

AND

Back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively: G9944

Numerator

THERE ARE TWO SUBMISSION CRITERIA FOR THIS MEASURE:

Percentage of patients 18 years of age or older as of October 1 of the denominator identification period who had a lumbar spine fusion procedure performed during the denominator identification period and whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (+/- 3 months) postoperatively.

Average of the change in pain preoperatively to post-operatively among patients having received a lumbar fusion.

NUMERATOR (SUBMISSION CRITERIA 1):

All eligible patients whose back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively

Definition:

Measure Assessment Period (Performance Period) – The period of time following the procedure date that is in which a postoperative VAS pain scale score is obtained.

Visual Analog Scale (VAS) – A visual analog scale is a continuous line indicating the continuum between two states of being. A copy of the tool can be obtained at Visual Analog Scale Tool

Visual Analog Pain Scale

Back Pain:

How severe is your back pain today?

Please place an “X” in a box below the line to indicate how bad you feel your back pain is today. Please select (“X”) only ONE box.

No Pain

________________________________________________________

Intolerable

No Pain

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

5.0

5.5

6.0

6.5

7.0

7.5

8.0

8.5

9.0

9.5

Intolerable

NUMERATOR NOTE: In the event that a patient’s pain is measured by the Visual Analog Scale (VAS) within three months preoperatively OR at one year (9 to 15 months) postoperatively, but not for both the preoperative and postoperative pain measurements, then submit Performance Not Met G9946. In the event that a patient’s pain measurement status is unknown OR was measured by the Visual Analog Scale (VAS) greater than three months preoperatively OR more than one year (9 to 15 months) postoperatively OR was measured using a different patient reported pain assessment tool for either the preoperative or postoperative pain measurement, then submit Performance Not Met G9946.

Numerator Options:

Performance Met:

Back pain was measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively (G9944)

Performance Not Met:

Back pain was not measured by the Visual Analog Scale (VAS) within three months preoperatively AND at one year (9 to 15 months) postoperatively (G9946)

–OR–

The average change (preoperative to one year postoperative) in back pain for all eligible patients

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