2024 QCDR Measure ID: AJRR11
Measure Title: Improvement in Pain Assessment Following Spine Fusion Procedures
Measure Description: Percentage of patients with patient-reported meaningful improvement in pain
following lumbar or cervical spine procedures.
Denominator: All patients ages 18 years and older undergoing a spinal fusion (cervical or lumbar), who
have a baseline, and within 1 year, a follow-up assessment for neck, back, arm, or leg pain.
Pain assessment is determined with the NRS (Numeric Rating Scale).
Numerator(s): Numerator 1: Percentage of denominator patients who showed a statistically significant
improvement in comparison to initial assessment, measured by minimum clinically important difference
(MCID), in neck pain. Numerator 2: Percentage of denominator patients who showed a statistically
significant improvement in comparison to initial assessment, measured by minimum clinically important
difference (MCID), in back pain. Numerator 3: Percentage of denominator patients who showed a
statistically significant improvement in comparison to initial assessment, measured by minimum
clinically important difference (MCID), in arm pain. Numerator 4: Percentage of denominator patients
who showed a statistically significant improvement in comparison to initial assessment, measured by
minimum clinically important difference (MCID) in leg pain.
Denominator Exclusions: None
Denominator Exceptions: None
Numerator Exclusions: None
High-Priority Measure/Type: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory; Hospital Inpatient; Hospital Outpatient
Number of performance rates required for measure: 4
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional Measure
MIPS Reporting Option: Traditional MIPS
Measure ID: AJRR12
Measure title: Physical Health Outcomes in Total Hip and Knee Arthroplasty
Measure Description: Percentage of patients with patient-reported meaningful improvement in
Denominator(s): Denominator 1: All patients ages 18 years and older undergoing an elective primary
total hip arthroplasty, who have a baseline, and within 1 year, a follow-up HOOS JR assessment.
Denominator 2: All patients ages 18 years and older undergoing an elective primary total knee
arthroplasty, who have a baseline, and within 1 year, a follow-up KOOS JR. anatomic specific
HOOS/KOOS JR after elective total hip and knee arthroplasty.
Numerator(s): Numerator 1: Percentage of denominator 1 patients who showed a statistically
significant improvement in comparison to initial assessment, measured by minimum clinically
important difference (MCID). Numerator 2: Percentage of denominator 2 patients who showed a
statistically significant improvement in comparison to initial assessment, measured by minimum
clinically important difference (MCID).
Denominator Exclusions: Patient who has a max score at baseline
Denominator Exceptions: None
Numerator Exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory; Hospital Inpatient; Hospital Outpatient
Number of performance rates required for measure: 2
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional Measure
MIPS Reporting Option: Traditional MIPS
Measure ID: AJRR9
Measure title: Risk-Standardized Routine Discharge Rate Following Elective Primary Hip and Knee
Arthroplasty
Measure Description: Risk-standardized rate for routine discharge for elective primary total hip and
knee arthroplasty
Denominator(s): Demoninator 1: All patients ages 18 years and older undergoing an elective primary
total hip arthroplasty. Denominator 2: All patients ages 18 years and older undergoing an elective
primary total knee arthroplasty.
Numerator(s): Numerator 1: A risk-standardized rate of routine discharge above the median risk-
standardized rate for denominator 1 patients. Numerator 2: A risk-standardized rate of routine
discharge above the median risk-standardized rate for denominator 2 patients. Routine discharge is
defined as having a CMS discharge disposition of “01” (routine discharge: home/self-care).
Denominator Exceptions: None
Denominator Exclusions: Denominator Exclusion 1: Documented medical, patient, or institutional
reason for non-routine discharge. Denominator Exclusion 2: Procedures from surgeons that do not
submit discharge disposition data.
Numerator Exclusions: None
High-priority status: Outcome
Measure type: Outcome
Care setting(s): Ambulatory; Hospital Inpatient; Hospital Outpatient
Number of performance rates required for measure: 2
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Ratio
Risk adjustment: Yes, Both rates are risk-adjusted for age, gender, and Charlson Comorbidity Index
(CCI) where applicable.
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK1
Measure title: Patients Suffering From a Neck Injury who Improve Physical Function
Measure Description: Percentage of patients 18 years or older suffering from a neck injury who
achieve the Minimal Clinically Important Difference (MCID) in the NDI or PROMIS Pain Interference, or
like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate: 1) The overall performance rate of non-surgical and surgical patients
who achieve the MCID in NDI/PROMIS Pain Interference/or like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a neck injury evaluated and treated by a Physical Therapist (PT), Occupational
Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with neck injuries to achieve an MCID in their NDI change
score (MCID > or = to 10) or (MCID < or = -2) in PROMIS Pain Interference change score or like mapped
measure, from their initial visits to their final visits in PT/OT practice or PT/OT group during the
performance year.
Denominator exceptions: 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 exclusions: 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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional Measure
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK2
Measure title: Patients Suffering From an Upper Extremity Injury who Improve Physical Function
Measure Description: Percentage of patients 18 years or older suffering from an upper extremity
injury who achieve the Minimal Clinically Important Difference (MCID) in the QDASH or PROMIS Upper
Extremity, or like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate: 1) The overall performance rate of non-surgical and surgical patients
who achieve the MCID in QDASH/PROMIS Upper Extremity/or like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with an upper extremity injury evaluated and treated by a Physical Therapist (PT),
Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with upper extremity injuries to achieve an MCID in their
QDASH change score (MCID > or = to 10) or (MCID > or = 2.1) in PROMIS Upper Extremity change score or like mapped measure, from their initial visits to their final visits in PT/OT practice or PT/OT group
during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK3
Measure title: Patients Suffering From a Back Injury who Improve Physical Function
Measure Description: Percentage of patients 18 years or older suffering from a back injury who
achieve the Minimal Clinically Important Difference (MCID) in the MDQ or PROMIS Pain Interference, or
like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in
MDQ/PROMIS Pain Interference/or like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a back injury evaluated and treated by a Physical Therapist (PT), Occupational
Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with back injuries to achieve an MCID in their MDQ change
score (MCID > or = to 10) or (MCID < or = -2) in PROMIS Pain Interference change score or like mapped
measure, from their initial visits to their final visits in PT/OT practice or PT/OT group during the
performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK4
Measure title: Patients Suffering From a Lower Extremity Injury who Improve Physical Function
Measure Description: Percentage of patients 18 years or older suffering from a lower extremity injury
who achieve the Minimal Clinically Important Difference (MCID) in the LEFS or PROMIS Physical
Function, or like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in
LEFS/PROMIS Physical Function/or like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a lower extremity injury evaluated and treated by a Physical Therapist (PT),
Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with lower extremity injuries to achieve an MCID in their
LEFS change score (MCID > or = to 10) or (MCID > or = 2.1) in PROMIS Physical Function change score
or like mapped measure, from their initial visits to their final visits in PT/OT practice or PT/OT group
during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Post-
Acute Care; Outpatient Services
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK5
Measure title: Patients Suffering From a Knee Injury who Improve Physical Function
Measure Description: Percentage of patients 18 years or older suffering from a knee injury who
achieve the Minimal Clinically Important Difference (MCID) in the KOS or PROMIS Physical Function, or
like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in
KOS/PROMIS Physical Function/or like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a knee injury evaluated and treated by a Physical Therapist (PT), Occupational
Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with knee injuries to achieve an MCID in their KOS change
score (MCID > or = to 10) or (MCID > or = 2.1) in PROMIS Physical Function change score or like mapped
measure, from their initial visits to their final visits in PT/OT practice or PT/OT group during the
performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK6
Measure title: Patients Suffering From a Neck Injury who Improve Pain
Measure Description: Percentage of patients 18 years or older suffering from a neck injury who
achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like
mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the
Numeric Pain Rating Scale like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a neck injury evaluated and treated by a Physical Therapist (PT), Occupational
Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with neck injuries to achieve an MCID in their Numeric Pain
Rating Scale change score (MCID > or = to 2) or like mapped measure, from their initial visits to their
final visits in PT/OT practice or PT/OT group during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK7
Measure title: Patients Suffering From an Upper Extremity Injury who Improve Pain
Measure Description: Percentage of patients 18 years or older suffering from an upper extremity
injury who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale,
or like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the
Numeric Pain Rating Scale like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with an upper extremity injury evaluated and treated by a Physical Therapist (PT),
Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with upper extremity injuries to achieve an MCID in their
Numeric Pain Rating Scale change score (MCID > or = to 2) or like mapped measure, from their initial
visits to their final visits in PT/OT practice or PT/OT group during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK8
Measure title: Patients Suffering From a Back Injury who Improve Pain
Measure Description: Percentage of patients 18 years or older suffering from a back injury who
achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like
mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the
Numeric Pain Rating Scale like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a back injury evaluated and treated by a Physical Therapist (PT), Occupational
Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with back injuries to achieve an MCID in their Numeric Pain
Rating Scale change score (MCID > or = to 2) or like mapped measure, from their initial visits to their
final visits in PT/OT practice or PT/OT group during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK9
Measure title: Patients Suffering From a Lower Extremity Injury who Improve Pain
Measure Description: Percentage of patients 18 years or older suffering from a lower extremity injury
who achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or
like mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the
Numeric Pain Rating Scale like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a lower extremity injury evaluated and treated by a Physical Therapist (PT),
Occupational Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with lower extremity injuries to achieve an MCID in their
Numeric Pain Rating Scale change score (MCID > or = to 2) or like mapped measure, from their initial
visits to their final visits in PT/OT practice or PT/OT group during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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.
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Measure ID: MSK10
Measure title: Patients Suffering From a Knee Injury who Improve Pain
Measure Description: Percentage of patients 18 years or older suffering from a knee injury who
achieve the Minimal Clinically Important Difference (MCID) in the Numeric Pain Rating Scale, or like
mapped measure during the performance year.
Additionally, a risk-adjusted MCID proportional difference determined by calculating the difference
between the risk model predicted and observed MCID proportion will be reported for each PT/OT/MSK
Provider/Group. The risk adjustment will be calculated using a logistic regression model using: baseline
function score, baseline pain score, age, sex, payer, surgical status, and symptom duration (time from
surgery or symptom onset to baseline physical therapy visit) as well as instrument tool used. These
measures will serve as a PT/OT/MSK Provider performance measure at the eligible PT/OT/MSK
Provider or group level.
This measure will include one rate:
1) The overall performance rate of non-surgical and surgical patients who achieve the MCID in the
Numeric Pain Rating Scale like mapped measure.
Denominator: The total number of all patients 18 years or older at the time of the initial evaluation or
start of care with a knee injury evaluated and treated by a Physical Therapist (PT), Occupational
Therapist (OT), or Musculoskeletal(MSK) Provider or group.
Numerator: The total number of patients with knee injuries to achieve an MCID in their Numeric Pain
Rating Scale change score (MCID > or = to 2) or like mapped measure, from their initial visits to their
final visits in PT/OT practice or PT/OT group during the performance year.
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 or follow a standard care pathway. The provider must clearly document in the medical
record the specific medical complexity / complexities present to qualify for this exception.
Denominator exclusions: 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
Numerator exclusions: None
High-priority status: Outcome
Measure type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Care setting(s): Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care;
Outpatient Services; Post-Acute Care
Telehealth, if applicable: Yes
Number of performance rates required for the measure: 1
Traditional vs. inverse measure: Traditional
Proportional, continuous variable, and/or ratio measure indicator: Proportional
Risk adjustment: Yes, 1st performance rate
MIPS Reporting Option: Traditional MIPS
Exclusive 2023 QCDR MIPS Measures: Exclusive 2023 Measures | OrthoQCDR