MIPS Quality Measures: Quick Reference

For these IROMS measures (and for #HM7), the first Outcome measurement MUST occur during the Initial Evaluation. The measure will only populate in the MIPS tab on the next evaluation note type where the same OMT was administered. This is because you must have at least two survey scores to compare and calculate the MCID (see below).

Measure	Associated Outcome	Required Diagnosis to Trigger OMT	MCID*
IROMS 19: Functional Status Change for Patients With Upper-limb Functional Status Deficit	QuickDASH	Diagnosis code related to the elbow, wrist, hand, or shoulder	8
IROMS 17:Functional Status Change for Patients With Low Back Functional Status Deficit	Modified Oswestry	Diagnosis code related to the low back i.e. stability/stenosis	6
IROMS 15: Functional Status Change for Patients With Neck Functional Status Deficit	Neck Disability Index	Diagnosis code related to the neck i.e. cervical/strain	7.5
IROMS 13: Functional Status Change for Patients With Lower Extremity Functional Status Deficit	Lower Extremity (LEFS)	Diagnosis code related to the foot, ankle, hip, knee, or pelvis	9
#HM7: Functional Status Change for Patients With Lower Extremity Functional Status Deficit	Dizziness Handicap	Diagnosis code related to the vestibular i.e. vertigo/migraine	18

*MCID = Minimal Clinically Important Difference. This is the minimum change required between the patient’s original survey score (Initial Evaluation) and 2nd survey (Progress Note/Discharge) to show that the treatment has been effective.

For IROMS measures, the MCID will be present in your MIPS Pro Portal. Remember, IROMS Measures are inverse measures, which means that if the MCID is met, it means that a patient failed to show progress over the given time span.

For #HM7, if the MCID is met, it means that the patient did, in fact, demonstrate improvement in their outcomes. If the difference is smaller than the MCID listed for the measure, you will not be able to select the first option for that measure in the MIPS tab (Performance Met).

MIPS Quality Measures: Qualification

Check out the following table for key qualification details or each MIPS measure.

Measure	Age	Reported with Procedure Codes	Required Diagnosis?
#126: Diabetic Foot and Ankle Care, Peripheral Neuropathy	18+	Initial Evaluation OR Re-Evaluation with 97161, 97162, 97163, 97164	Yes
#127: Diabetic Foot and Ankle Care,Ulcer Prevention-Evaluation of Footwear	18+	Initial Evaluation OR Re-Evaluation with 97161, 97162, 97163, 97164	Yes
#128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	18+	Initial Evaluation with PT: 97161, 97162, 97163, OT: 97165, 97166, 97167	No
#130: Documentation and Verification of Current Medications in the Medical Record	18+	Initial Evaluation, Re-Evaluation, OR Discharge Summary with PT: 97161, 97162, 97163, 97164, OT: 97165, 97166, 97167, 97168, SLP: 92521, 92522, 92523	No
#134: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan	12+	Initial Evaluation with PT: 97161, 97162, 97163, OT: 97165, 97166, 97167	No
#155: Falls: Plan of Care	65+	Initial Evaluation OR Re-Evaluation PT: 97161, 97162, 97163, 97164, OT: 97165, 97166, 97167, 97168	No
#181: Elder Maltreatment Screen and Follow-Up Plan	65+	Initial Evaluation with, PT: 97161, 97162, 97163, OT: 97165, 97166, 97167, SLP: 92521, 92522, 92523	No
#182: Functional Outcome Assessment	18+	Initial Evaluation, Re-Evaluation, and Discharge Summary with PT: 97161, 97162, 97163, 97164, OT: 97165, 97166, 97167, 97168, SLP: 92610, 92611, 92612	No
#226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	18+	Initial Evaluation OR Re-Evaluation with OT: 97165, 97166, 97167, 97168, SLP: 92521, 92522, 92523, 92524	No
IROMS 19: Functional Status Change for Patients With Upper-limb Functional Status Deficit	18+	Initial Evaluation AND Re-Evaluation or Discharge Summary	Yes
IROMS 17:Functional Status Change for Patients With Low Back Functional Status Deficit	18+	Initial Evaluation AND Re-Evaluation or Discharge Summary	Yes
IROMS 15: Functional Status Change for Patients With Neck Functional Status Deficit	18+	Initial Evaluation AND Re-Evaluation or Discharge Summary	Yes
IROMS 13: Functional Status Change for Patients With Lower Extremity Functional Status Deficit	18+	Initial Evaluation AND Re-Evaluation or Discharge Summary	Yes
#HM7: Functional Status Change for Patients With Lower Extremity Functional Status Deficit	18+	Initial Evaluation AND Re-Evaluation or Discharge Summary	Yes