Measure 182: Functional Outcome Assessment (SOAP 2.0)

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

Standardized outcome assessments, questionnaires, or tools are a vital part of evidence-based practice. 

Using standardized tests and measures early in an episode of care establishes the patient’s baseline status and provides the ability to quantify the change in the patient's functioning. 

This is a high priority measure and is eligible for one additional bonus point when reported with another high priority measure.

Note: This measure does not have a benchmark and is capped at 3 points.  

Who can report this measure?

PTs, OTs, and SLPs can report on this measure through the WebPT EMR MIPS functionality.

Patient Qualifications

  • Patient age (18 or older)
  • Visit Type: Initial Evaluation, Re-Evaluation, and Discharge Summary

When do I report on this measure?

Measure 182 is reported at each eligible visit or at least every 30 days, for patients seen during the performance period when an eligible procedure code is billed.  

Eligible Procedure Codes

PT: 97161, 97162, 97163, 97164

OT: 97165, 97166, 97167, 97168

SLP: 92610, 92611, 92612

Measure Requirements

  • Documented functional outcome assessment using a standardized functional outcome assessment tool (a tool that has been normed and validated).
  • Documentation of a Care Plan based on identified functional outcome deficiencies on the date of the identified deficiencies

Measure Specification

For more information on Measure 182, please see the Measure Specification Guide.

Measure Reporting in WebPT

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

Objective Tab

  1. 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.
  2. On the Objective section, select the Standardized Tests subsection to view and edit the required fields for Measure 182.
  3. Select the Add Standardized Test+ link.
  4. Use the drop down menu to select a standardized functional outcome assessment tool. A functional outcome assessment is multi-dimensional and measures the quantity of pain and musculoskeletal/neuromusculoskeletal capacity.

    Note: You may select any of the surveys in WebOutcomes to fulfill this measure. Do not select the Berg Balance Scale or the Bates-Jensen Wound Assessment Tool, as these are not surveys. Do not select an OMT that assesses only pain as noted in the OMT Pain Category, as these will not comply with the measure requirements.
  5. In this example, we’ll select the Modified Oswestry Low Back Pain Disability Questionnaire, as our patient presented with a lower back pain diagnosis.
  6. Next, administer the OMT and record the results by selecting the drop-down menus.
  7. The EMR will calculate the Total Score and Disability in Percent automatically.
  8. Given the patient’s result, you should tailor your documentation in the Assessment and Plan tabs to address the patient’s functional definitions including Treatment to be provided and Goals. This information should form the required Plan of Care.

Assessment Tab

  1. On the Assessment section, select the Problems & Goals subsection to view and edit the required fields for Measure 182.
  2. Measure Met: If you have documented the Plan of Care to identify functional outcome deficiencies, select the checkbox. This triggers a Measure Met indicator in the Measure Status column.
  3. Given the patient’s result, you should tailor your documentation in the Assessment and Plan tabs to address the patient’s functional definitions including Treatment to be provided and Goals. This information should form the required Care Plan.
  4. Excluded: Select the Excluded radio button if the patient meets any of the following reasons, then enter the Reason in the required field:
    • Patient refuses to participate
    • Patient unable to complete questionnaire
    • Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
    • Functional outcome assessment NOT documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool at the time of the encounter
    • Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan at the time of the encounter
  5. Not Met: Select the Not Met radio button if :
    • Functional outcome assessment using a standardized tool not documented, reason not given
    • Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented, reason not given
  6. If the note is signed without completing the required fields, an alert will appear. Required fields must be completed before submitting the note.