Measure 154: Falls: Risk Assessment (SOAP 2.0)
This is a guide for 2.0 measure reporting. For 1.0 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 this measure.
- 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
- 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.
For more information on Measure 154, please see the Measure Specification Guide.
Measure Reporting in the WebPT EMR
This measure is reported on the Subjective and Objective tabs. Let’s review.
In the Past 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.
- Click the MIPS badge in the Case Summary to view the current Measure Status. Here you will see all measures that the patient is eligible for based on their Diagnoses and Procedure Code.
- On the Subjective section, select the appropriate radio buttons in the History of Falls to answer the required field for Measure 154.
- If the patient does not have a history of falls, continue documenting; you’ve satisfied the measure requirements for Not Eligible Patients.
- If the patient does have a history of falls, select at least one falls risk evaluation for the Fall Risk Plan section.
- On the Objective section, select Standardized Tests to expand the section.
- Select Add Standardized Test+ to complete a Risk Assessment for patients with a “positive” fall risk.
- Use the drop-down menu to select at least one Balance/Gait Assessment (Berg Balance Scale, Dynamic Galt Index, Times Up and Go Test)
- The test appears in the Standardized Tests section. In this example, we’ve selected the Times Up and Go (TUG) Test but the steps are the same regardless of which test you’ve chosen.
- Administer the test and record the result.
- Measure Met: Enter the Summary of Performance to satisfy measure requirements. This triggers a Measure Met indicator in the Measure Status column. When finished documenting, validate the selection in the MIPS tab.
- Excluded: Select the Excluded radio button if the patient meets any of the following reasons, then select the Reason in the required field:
- Documentation of medical reason(s) for not completing a risk assessment (i.e., patient is bed ridden, immobile, wheelchair bound)
- Hospice services for the patient are provided during the measurement period
- Not Met: Select the Not Met radio button if falls risk assessment not completed, reason not otherwise specified.
- If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.
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. Select the Not Met radio button for Measure 154 on the Measure Status column.