Limber Health is a CMS-Approved Qualified Clinical Data Registry (QCDR)

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 (> or = to -7.5) or ( > 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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a neck injury who achieve an overall score change of > or = the MCID in the NDI, PROMIS Pain Interference or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 (> or = to -8) or (> 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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a knee injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 (> or = to -6) or (> 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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a low back injury who achieve an overall score change of > or = the MCID in the MDQ, PROMIS Pain Interference or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 (> or = to 9) or (> 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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a low back injury who achieve an overall score change of > or = the MCID in the MDQ, PROMIS Pain Interference or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 (> or = to 10) or (> 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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a knee injury who achieve an overall score change of > or = the MCID in the KOS, PROMIS Physical Function or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a neck injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with an upper extremity injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a low back injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a low back injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes

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 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
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.
Numerator Exclusions: None
‍
High Priority Measure? Yes
High Priority Type: Outcome
Measure Type: Patient-Reported Outcome-based Performance Measure (PRO-PM)
Inverse Measure: No
Proportional Measure: Yes
Continuous Variable Measure: No
Ratio Measure: No
Number of Performance Rates to be submitted: 1
Performance Rate Description(s): This measure will include the combined rate of;Rate 1) Total number of patients aged 18 years or older with a knee injury who achieve an overall score change of > or = the MCID in the NPRS, or like mapped measure.
Overall Performance Rate: 1st Performance Rate
Measure Risk-Adjusted?: Yes
If Risk-Adjusted, indicate which Score is Risk-Adjusted: 1st performance rate
MIPS Reporting Options: Traditional MIPS
Care Setting: Ambulatory Care: Clinician Office/Clinic; Ambulatory Surgical Center; Home Care; Outpatient Services; Post-Acute Care
Includes Telehealth? Yes