qdcr

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

Why Choose Limber Health for your MIPS reporting?

  • Experts in registry design
  • Innovative approach to get the highest completion rates
  • Patient-reported outcome measures (PROMs) used by leading academic institutions
  • Computer adaptive format, decreasing survey fatigue on patients
  • Seamlessly integrate within your clinical workflow 

2023 Limber Health Outcomes Quality Measure Specifications

LMBR1

Measure Title: Patients Suffering From a Knee Injury who Improve Physical Function

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description:  Percentage of patients 18 years or older suffering from a Knee injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Physical Function Computer Adaptive Testing, mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Physical Function or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Physical Function or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined.

Denominator: All patients 18 years or older with a knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator: Number of patients aged 18 years or older with a knee injury who achieve an overall score change of 2.1 points in PROMIS Physical Function or like mapped measure.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

LMBR2:

Measure Title: Patients Suffering From a Lumbar Spine (Low Back) Injury who Improve Physical Function

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from a Lumbar Spine (Low Back) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Physical Function Computer Adaptive Testing, mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Physical Function  or like mapped measure.

2) The number of surgical patients achieving a score change greater than or equal to the MCID in PROMIS Physical Function or like mapped measure 

3) The overall performance rate of Rate 1 and Rate 2 combined. 

Denominator: All patients 18 years or older with a lumbar spine (low back) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period. 

Numerator: Number of patients aged 18 years or older with a lumbar spine (low back) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function or like mapped measurement tool.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR3:

Measure Title: Patients Suffering From a Cervical Spine (Neck) Injury who Improve Physical Function

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from a Cervical Spine (neck) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Physical Function Computer Adaptive Testing, mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Physical Function or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Physical Function  or like mapped measure

3) The overall performance rate of Rate 1 and Rate 2 combined. 

Denominator: All patients 18 years or older with a cervical spine (neck) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator: Number of patients aged 18 years or older with a cervical spine (neck) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function or like mapped measurement tool.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

Measure Title: Patients Suffering From a Lower Extremity Injury who Improve Physical Function

Measure Owner: Patient360 in Colaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from a hip, foot, or ankle injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Physical Function Computer Adaptive Testing, mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Physical Function or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Physical Function or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined. 

Denominator: All patients 18 years or older with a hip,foot, or ankle injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator: Number of patients aged 18 years or older with a hip injury who achieve an overall score change of 2.1 points in PROMIS Physical Function or like mapped measurement tool.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR5 

Measure Title: Patients Suffering From a Upper Extremity Injury who Improve Physical Function

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from a shoulder, elbow, wrist/hand injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing in the PROMIS Pain Interference Computer Adaptive Testing (CAT), mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Upper Extremity Function or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS PROMIS Upper Extremity Function or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined.  

Denominator:All eligible patients 18 years or older with shoulder, elbow, wrist/hand injury evaluated and treated by a physical therapist (PT) or physical therapy group with a hip, ankle, or foot injury at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period. 

Numerator: Number of patients aged 18 years or older with shoulder, elbow, wrist/hand injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference or like mapped measurement tool.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR6:

Measure Title: Patients Suffering From a Knee Injury who Demonstrate Improved Pain

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from knee pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT), mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Pain Interference  or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure. 

3) The overall performance rate of Rate 1 and Rate 2 combined. 

Denominator: All patients 18 years or older with knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.  

Numerator: Number of patients aged 18 years or older with knee injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference or or like mapped measurement tool..

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR7 

Measure Title: Patients Suffering From a Lumbar Spine (Low Back) Injury who Demonstrate Improved Pain

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from lumbar spine (low back) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT), mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined. 

 Denominator: All patients 18 years or older with lumbar spine (low back) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.  

Numerator: Number of patients aged 18 years or older with lumbar spine (low back) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference or or like mapped measurement tool..

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR8 

Measure Title: Patients Suffering From a Cervical Spine (Neck) Injury who Demonstrate Improved Pain

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from cervical spine (neck) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT), mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined. 

Denominator: All patients 18 years or older with cervical spine (neck) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.  

Numerator: Number of patients aged 18 years or older with cervical spine (neck) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference or like mapped measurement tool..

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR9 

Measure Title: Patients Suffering From a Lower Extremity Injury who Demonstrate Improved Pain

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description: Percentage of patients 18 years or older suffering from hip, ankle, or foot injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT), mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined.

Denominator: All eligible patients 18 years or older with hip, ankle, or foot injury evaluated and treated by a physical therapist (PT) or physical therapy group with a hip, ankle, or foot injury at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period. 

Numerator: Number of patients aged 18 years or older with hip, ankle, or foot injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference or like mapped measurement tool.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes   High Priority Type: OUTCOMES

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

NQS Domain: Effective Clinical Care

Care Setting: Ambulatory Care: Clinician Office/Clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional Outcomes

LMBR10 

Measure Title: Patients Suffering From a Upper Extremity Injury who Demonstrate Improved Pain

Measure Owner: Patient360 in Collaboration with ETSU & Limber Health

Measure Description

Percentage of patients 18 years or older suffering from shoulder, elbow, wrist/hand injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT), mapped legacy measure, or like tool of measurement. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score. 

In order to fairly measure performance between providers, the measure is risk-adjusted based on age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

1) The number of non-surgical patients achieving a score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

2) The number of surgical patients achieving a  score change greater than or equal to the MCID in PROMIS Pain Interference or like mapped measure.

3) The overall performance rate of Rate 1 and Rate 2 combined

Denominator: All patients 18 years or older with shoulder, elbow, wrist/hand injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period. 

Numerator: Number of patients aged 18 years or older with shoulder, elbow, wrist/hand pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference or like mapped measurement tool.

Denominator Exclusions: Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire. This will be determined by the physical therapist at the time of the evaluation. Patients where score change cannot be measured due to lack of 2+ completed surveys within the measurement window. 

Denominator Exceptions: Physical Therapists can exclude patients based on an evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway. Patients may also be excluded if they are seen for less than 3 visits. 

High Priority Measure? Yes    High Priority Type: Outcome

Measure Type: Patient reported outcome based performance measure

NQS Domain: effective clinical care

Care Setting: ambulatory care: clinician office/ clinic

Includes Telehealth? Yes

Which Meaningful Measure Area applies to this measure? Functional outcomes

2022 Limber Health Outcomes Quality Measure Specifications

Quality Metrics:

Measure Title:

Patient 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 PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering knee functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR1

Denominator:

All patients 18 years or older with a knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a knee injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Lumbar Spine (Low Back) Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a lumbar spine (low back) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering low back functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR2

Denominator:

All patients 18 years or older with a lumbar spine (low back) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a lumbar spine (low back) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Cervical Spine (Neck) Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a cervical spine (neck) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering neck functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR3

Denominator:

All patients 18 years or older with a cervical spine (neck) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a cervical spine (neck) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Hip Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a hip injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering hip functional deficits.This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR4

Denominator:

All patients 18 years or older with a hip injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a hip injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic 

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Shoulder Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a shoulder injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Upper Extremity is unique and validated for patients suffering shoulder functional deficits.This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Upper Extremity
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Upper Extremity
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR5

Denominator:

All patients 18 years or older with a shoulder injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a shoulder injury who achieve an overall score change of 2.1 points in PROMIS Upper Extremity.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes 

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Knee Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from knee injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering knee functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR6

Denominator:

All patients 18 years or older with knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with knee injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Lumbar Spine (Low Back) Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from lumbar spine (low back) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering low back functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR7

Denominator:

All patients 18 years or older with lumbar spine (low back) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with lumbar spine (low back) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Cervical Spine (Neck) Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from cervical spine (neck) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering neck functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR8

Denominator:

All patients 18 years or older with cervical spine (neck) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with cervical spine (neck) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcome 

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Hip Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from hip injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering hip functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined.To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR9

Denominator:

All patients 18 years or older with hip injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with hip injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Shoulder Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from shoulder pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering shoulder functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR10

Denominator:

All patients 18 years or older with shoulder pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with shoulder pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Improvement Activities

Activity

IA_BE_6

Activity Name

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement 

Activity Description

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.

Subcategory Name

Beneficiary Engagement

Activity Weighting

High


Activity

IA_BE_7

Activity Name

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

Activity Description

Participation in a Qualified Clinical Data Registry (QCDR), that promotes patient engagement, including:

  • Use of processes and tools that engage patients for adherence to treatment plans;
  • Implementation of patient self-action plans;
  • Implementation of shared clinical decision making capabilities; or
  • Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium

 

Activity

IA_BE_8

Activity Name

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

Activity Description

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

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium 

 

Activity

IA_BE_22

Activity Name

Improved Practices that Engage Patients Pre-Visit

Activity Description

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium


Activity

IA_AHE_3

Activity Name

Promote Use of Patient-Reported Outcome Tools

Activity Description

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.

Subcategory Name

Achieving Health Equity

Activity Weighting

High

Why Choose Limber Health Outcomes QCDR for your MIPS reporting?

  • Experts in registry design
  • Innovative approach to get the highest completion rates
  • Patient-reported outcome measures (PROMs) used by leading academic institutions
  • Computer adaptive format, decreasing survey fatigue on patients
  • Seamlessly integrate within your clinical workflow 

2022 Limber Health Outcomes Quality Measure Specifications

Quality Metrics:

Measure Title:

Patient 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 PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering knee functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR1

Denominator:

All patients 18 years or older with a knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a knee injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Lumbar Spine (Low Back) Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a lumbar spine (low back) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering low back functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR2

Denominator:

All patients 18 years or older with a lumbar spine (low back) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a lumbar spine (low back) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Cervical Spine (Neck) Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a cervical spine (neck) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering neck functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR3

Denominator:

All patients 18 years or older with a cervical spine (neck) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a cervical spine (neck) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Hip Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a hip injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering hip functional deficits.This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR4

Denominator:

All patients 18 years or older with a hip injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a hip injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic 

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Shoulder Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a shoulder injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Upper Extremity is unique and validated for patients suffering shoulder functional deficits.This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Upper Extremity
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Upper Extremity
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR5

Denominator:

All patients 18 years or older with a shoulder injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a shoulder injury who achieve an overall score change of 2.1 points in PROMIS Upper Extremity.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes 

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Knee Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from knee injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering knee functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR6

Denominator:

All patients 18 years or older with knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with knee injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Lumbar Spine (Low Back) Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from lumbar spine (low back) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering low back functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR7

Denominator:

All patients 18 years or older with lumbar spine (low back) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with lumbar spine (low back) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Cervical Spine (Neck) Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from cervical spine (neck) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering neck functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR8

Denominator:

All patients 18 years or older with cervical spine (neck) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with cervical spine (neck) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcome 

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Hip Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from hip injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering hip functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined.To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR9

Denominator:

All patients 18 years or older with hip injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with hip injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Shoulder Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from shoulder pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering shoulder functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR10

Denominator:

All patients 18 years or older with shoulder pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with shoulder pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Improvement Activities

Activity

IA_BE_6

Activity Name

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement 

Activity Description

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.

Subcategory Name

Beneficiary Engagement

Activity Weighting

High


Activity

IA_BE_7

Activity Name

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

Activity Description

Participation in a Qualified Clinical Data Registry (QCDR), that promotes patient engagement, including:

  • Use of processes and tools that engage patients for adherence to treatment plans;
  • Implementation of patient self-action plans;
  • Implementation of shared clinical decision making capabilities; or
  • Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium

 

Activity

IA_BE_8

Activity Name

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

Activity Description

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

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium 

 

Activity

IA_BE_22

Activity Name

Improved Practices that Engage Patients Pre-Visit

Activity Description

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium


Activity

IA_AHE_3

Activity Name

Promote Use of Patient-Reported Outcome Tools

Activity Description

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.

Subcategory Name

Achieving Health Equity

Activity Weighting

High

Why Choose Limber Health Outcomes QCDR for your MIPS reporting?

  • Experts in registry design
  • Innovative approach to get the highest completion rates
  • Patient-reported outcome measures (PROMs) used by leading academic institutions
  • Computer adaptive format, decreasing survey fatigue on patients
  • Seamlessly integrate within your clinical workflow 

2022 Limber Health Outcomes Quality Measure Specifications

Quality Metrics:

Measure Title:

Patient 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 PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering knee functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics. 

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR1

Denominator:

All patients 18 years or older with a knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a knee injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Lumbar Spine (Low Back) Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a lumbar spine (low back) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering low back functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR2

Denominator:

All patients 18 years or older with a lumbar spine (low back) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a lumbar spine (low back) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Cervical Spine (Neck) Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a cervical spine (neck) injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering neck functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR3

Denominator:

All patients 18 years or older with a cervical spine (neck) injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a cervical spine (neck) injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Hip Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a hip injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Physical Function is unique and validated for patients suffering hip functional deficits.This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Physical Function
  2. The number of surgical patients achieving a a score change of 2.1 points  in PROMIS Physical Function
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR4

Denominator:

All patients 18 years or older with a hip injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a hip injury who achieve an overall score change of 2.1 points in PROMIS Physical Function.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic 

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Shoulder Injury who Improve Physical Function

Measure Description:

Percentage of patients 18 years or older suffering from a shoulder injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Upper Extremity Computer Adaptive Testing. The MCID for PROMIS Upper Extremity is unique and validated for patients suffering shoulder functional deficits.This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.1 points  in PROMIS Upper Extremity
  2. The number of surgical patients achieving a score change of 2.1 points  in PROMIS Upper Extremity
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR5

Denominator:

All patients 18 years or older with a shoulder injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with a shoulder injury who achieve an overall score change of 2.1 points in PROMIS Upper Extremity.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes 

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Knee Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from knee injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering knee functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR6

Denominator:

All patients 18 years or older with knee injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with knee injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

 

Measure Title:

Patients Suffering From a Lumbar Spine (Low Back) Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from lumbar spine (low back) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering low back functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR7

Denominator:

All patients 18 years or older with lumbar spine (low back) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with lumbar spine (low back) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Cervical Spine (Neck) Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from cervical spine (neck) pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering neck functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR8

Denominator:

All patients 18 years or older with cervical spine (neck) pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with cervical spine (neck) pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcome 

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Hip Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from hip injury who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering hip functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined.To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR9

Denominator:

All patients 18 years or older with hip injury evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with hip injury who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Measure Title:

Patients Suffering From a Shoulder Injury who Demonstrate Improved Pain

Measure Description:

Percentage of patients 18 years or older suffering from shoulder pain who achieve the Minimal Clinically Important Difference (MCID) in the PROMIS Pain Interference Computer Adaptive Testing (CAT). The MCID for PROMIS Pain Interference is unique and validated for patients suffering shoulder functional deficits. This measure will be reported as the overall number of patients of rate 1 and rate 2 combined. To qualify, the patient must complete a baseline score and then one follow-up or discharge score.

In order to fairly measure performance between providers' performance, the measure is risk-adjusted based on a proprietary assessment including age, sex, symptom characteristics, PROMIS baseline scores, social determinants of health, and psychosocial metrics.

This measure will include three rates:

  1. The number of non-surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  2. The number of surgical patients achieving a score change of 2.0 points  in PROMIS Pain Interference
  3. The overall performance rate of Rate 1 and Rate 2 combined

Measure ID:

LMBR10

Denominator:

All patients 18 years or older with shoulder pain evaluated and treated by a physical therapist (PT) or physical therapy group at the beginning of the measurement period with at least one eligible follow up encounter during the measurement period.

Numerator:

Number of patients aged 18 years or older with shoulder pain who achieve an overall score change of 2.0 points in PROMIS Pain Interference.

Denominator Exclusions

Patients who are under the age of 18. Patients who are non-English speaking or/and can not read. Patients who have severe mental or cognitive deficits limiting the accuracy of their questionnaire.  This will be determined by the physical therapist at the time of the evaluation.

Denominator Exceptions

Physical Therapists can exclude patients based on a full initial evaluation who may have severe comorbidities or demonstrate medical complexity that does not follow a standard care pathway.

Numerator Exclusions:

None

NQS Domain

Effective Clinical Care

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 calculated

1

High Priority Status

Yes

Meaningful Measurement Area

Functional Outcomes

Care Settings

Ambulatory Care: Clinician Office/Clinic

Telehealth Status

Yes

Risk Adjustment Status

Yes

Improvement Activities

Activity

IA_BE_6

Activity Name

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement 

Activity Description

Collection and follow-up on patient experience and satisfaction data on beneficiary engagement, including development of improvement plan.

Subcategory Name

Beneficiary Engagement

Activity Weighting

High


Activity

IA_BE_7

Activity Name

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

Activity Description

Participation in a Qualified Clinical Data Registry (QCDR), that promotes patient engagement, including:

  • Use of processes and tools that engage patients for adherence to treatment plans;
  • Implementation of patient self-action plans;
  • Implementation of shared clinical decision making capabilities; or
  • Use of QCDR patient experience data to inform and advance improvements in beneficiary engagement.

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium

 

Activity

IA_BE_8

Activity Name

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

Activity Description

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

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium 

 

Activity

IA_BE_22

Activity Name

Improved Practices that Engage Patients Pre-Visit

Activity Description

Implementation of workflow changes that engage patients prior to the visit, such as a pre-visit development of a shared visit agenda with the patient, or targeted pre-visit laboratory testing that will be resulted and available to the MIPS eligible clinician to review and discuss during the patient’s appointment.

Subcategory Name

Beneficiary Engagement

Activity Weighting

Medium


Activity

IA_AHE_3

Activity Name

Promote Use of Patient-Reported Outcome Tools

Activity Description

Demonstrate performance of activities for employing patient-reported outcome (PRO) tools and corresponding collection of PRO data such as the use of PHQ-2 or PHQ-9, PROMIS instruments, patient reported Wound-Quality of Life (QoL), patient reported Wound Outcome, and patient reported Nutritional Screening.

Subcategory Name

Achieving Health Equity

Activity Weighting

High