Measure 154: Falls: Risk Assessment

This is a guide for 1.0 measure reporting. For 2.0 measure reporting, click here.

Managing fall risk in elderly individuals is a regular occurrence for Physical and Occupational Therapists. Half of the time, a fall (or “near fall”) is why patients come to therapy in the first place! This is a high priority measure and is eligible for one additional bonus point when reported with another high priority measure. And, unlike most measures that therapists report, this topic comes with a linked set of 2 measures:

  • #154 – Falls: Risk Assessment
  • #155 – Falls: Plan of Care

Note: This measure has been classified as topped out and is capped at 7 points.

Who can report this measure?

PTs and OTs can report on this measure.

Patient Qualifications

  • Patient age (65 or older)
  • Visit type: Initial Evaluation or Re-Evaluation

When do I report on this measure?

Reporting is once per performance period and only when an eligible procedure code is billed.

Eligible Procedure Codes

  • PT: 97161, 97162, 97163, 97164
  • OT: 97165, 97166, 97167, 97168

Measure Requirements

  • First, determine whether the patient has fallen within the last 12-months (patient-reported history is acceptable)
  • If the patient has had two or more falls in the past year or any fall with injury in the past year, they have a “positive” fall risk.
  • Therapists must complete a Risk Assessment for patients with a “positive” fall risk. The Risk Assessment includes a Balance/Gait Assessment and at least one of the following:
    • Medications Assessment - Medical record must include documentation of whether the patient’s current medications may or may not contribute to falls.
    • Home fall hazards Assessment - Medical record must include documentation of counseling on home falls hazards, documentation of inquiry of home fall hazards, or referral for evaluation of home fall hazards.
    • Postural blood pressure - Documentation of blood pressure values in supine and then standing positions.
    • Vision Assessment - Medical record must include documentation that the patient is functioning well with vision or not functioning well with vision. This must be based on discussion with the patient, use of a standardized scale or assessment tool (e.g., Snellen), or documentation of referral for assessment of vision.
  • Patients who received hospice services during the measurement period are excluded.

Measure Specification

For more information on Measure 154, please see the Measure Specification Guide.

Measure Reporting in WebPT

This measure is reported on the Subjective and Objective tabs. Let’s review.

Subjective Tab

In the Medical History section, determine whether the patient has a history of falls (two or more falls or any fall with injury) for the last 12 months.

  1. In the History of Falls section, select Yes if the patient has a history of falls or N/A if the patient does not meet the history of falls criteria. Do not select the No button, use the N/A button if the patient does not have a history of falls and continue documenting.
  2. If the patient does have a History of Falls, you’ll need to complete the Falls Documented section. Select the Yes radio button and enter information to support your above selection.
  3. If the patient does not have a history of falls, continue documenting; you’ve satisfied the measure requirements for Not Eligible Patients. 
  4. If the patient does have a history of falls, select at least one contributing factor for the Risk Assessment section.

Objective Tab

  1. To complete the measure requirements for patients at risk for falls, select at least one Balance/Gait Assessment from Measure 154 in the MIPS Measure Tests section. 
  2. The test appears in the Outcome Measurement Tools section. In this example, we’ve selected the Dynamic Gait Index but the steps are the same regardless of which test you’ve chosen.  
  3. Use the Yes radio button to open the OMT. 
  4. Administer the test and record the result. 
  5. When finished documenting, validate the selection in the MIPS tab.

How do I report Measure 154 when the patient does not require falls risk screening?

If the patient does not have a history of falls as defined by the measures you do not need to complete any documentation. The N/A radio button is selected by default for all patients 65 or older and the system will pre-select the “Patient not eligible, No documentation of falls status” option for Measure 154 on the MIPS tab.

MIPS Tab: Reporting Selections

In the MIPS tab, the system will automatically select the measure that best fits your documentation. Below, we’ve indicated which selections meet the performance expectations.