Measure IROMS 15: Functional Status Change for Patients With Neck Functional Status Deficit

IROMS 15: Functional Status Change for Patients With Neck Functional Status Deficit is a calculated value derived from the completion of the Neck Disability Index (NDI), a patient-reported survey. To complete the NDI, patients are asked to select their relative impairment on a six-point scale for each of ten categories, including pain, personal care, lifting, reading, headaches, concentration, work, driving, sleeping, and recreation. Answers are scored from “0” (no disability) to “5” (complete disability).

To calculate the functional status change for IROMS 15, patients must complete the NDI at least twice during their episode of care. If the NDI surveys are administered on paper, the surveys must be filled out electronically for the risk adjusted MCID calculation.

Note: 

  • Currently, this measure does not have a benchmark and is capped at 3 points. CMS has indicated that they intend to use 2021 performance data to establish a performance benchmark for this measure, so we anticipate that this measure will be worth up to 10 points for the 2022 reporting period. 

  • This is a guide for SOAP 1.0 measure reporting. Click here to learn how to document IROMS 15 IN SOAP 2.0. 

Clinic Settings

We recommend enabling Show entire OMT questionnaire when clicking on OMT scorebox in Clinic Settings. Enabling this feature displays the full OMT when the score field is selected and requires each question on the OMT to be answered.

Who can report this measure? 

PTs and OTs can report on this measure. 

Important: This is a QCDR Measure. QCDR Measures are not included in the annual QPP measure set and are specific to the submitting QCDR. WebPT has partnered with Healthmonix to make these outcome measures available to you.

Measure Type

IROMS 15 is an outcome quality measure and satisfies the outcome measure reporting requirement for PTs and OTs. IROMS 15 may also be referred to as KEET01 starting in 2022. 

Patient Eligibility

Patients who meet any of the criteria below are not eligible to complete IROMS OMTs:

  • Patient has a life expectancy of less than 6 months
  • Patient is non-English speaking and translation services are unavailable
  • Patient has a mental or cognitive impairment that compromises their ability to complete the OMT
  • Patient meets Medicare requirements for maintenance therapy
  • Ongoing care not indicated
  • Patient is extremely medically complex and likely to make poor clinical progress

When do I report on this measure?

IROMS 15 is tied to note types, not procedure codes (unlike measures in the QPP set). You’ll report this measure when the following is true:

  • The patient is 18 years of age or older,
  • The patient has a diagnosis related to their neck functionality. See the Diagnoses that Trigger Reporting (ICD-10) section below.
  • The visit type is Initial Evaluation, Re-Evaluation, and/or Discharge
Important : To report the measure, you must have document the NDI on the Initial Evaluation.

Measure Requirements

IROMS 15 is measured through the completion of at least two NDI surveys by the patient. The first outcome measurement must occur during the Initial Evaluation. The next must occur on a Discharge.
Note: Scores captured on Progress Notes (PN) will be used to calculate the MCID where no Discharge (DS) score exists. (This ensures that patients who self-discharge can still be reported.)
Successful reporting of the measure requires a Minimum Clinically Important Difference (MCID) of 7.5. This means that the patient’s reported scores must decrease by 7.5 points to contribute positively to your MIPS score. After you collect two survey scores, the MCID will be calculated. We partnered with Healthmonix to provide these measures, and they will apply the risk adjustment formula to the MCID score. The risk-adjusted score will be available in your MIPSPro account.

Measure Reporting in the WebPT EMR 

  1. On the Subjective tab, select Yes for Surgery Performed if the patient has recently had surgery directly related to the episode of care. This field is required for accurate measure calculations.
  2. In the Medical History section of the Subjective Tab, use the radio buttons to indicate if your patient is eligible to complete IROMS OMTs. Click here to view patient exclusions and exceptions.
  3. Then, on the Objective tab, navigate to the Outcome Measurement Tools section and choose the Neck Disability Index Questionnaire from the ‘Select a questionnaire’ drop-down.

  4. From the Neck Disability Index section, click Show Test and complete the survey. If you have staged the survey using one of our intake methods, select the correct survey date and click Get Score.

  5. Complete documentation (including all appropriate MIPS measures) and finalize the note.

  6. During the patient’s next evaluation (Progress Note/Discharge), go to the Objective tab, select Show Test, and complete the OMT. If you have staged the survey using one of our intake methods, select the correct survey date and click Get Score (See image in step 4). The previous score will remain until it’s replaced.

  7. WebPT will automatically calculate the patient’s MCID and apply the risk adjustment formula. The appropriate option for this measure will be automatically selected on the MIPS tab, and the patient’s score will be visible in your MIPSPro account.

    Important: The measure will only appear on the MIPS tab after the patient has completed the OMT twice.

MIPS Tab Reporting Selections

On the MIPS tab, the system will automatically select the option that best fits your documentation.

A) You have documented both of the OMTs necessary to calculate the patient’s MCID. The MCID has been calculated, the risk adjustment applied, and is available in your MIPSPro account.

B) Your patient is Excluded from the measure for one of the reasons listed.

C) Your patient is Excepted from this measure for one of the reasons listed.

Diagnoses that Trigger Reporting (ICD-10)

  • Cervicogenic headache: G44*, M99.00, M99.01, R51*
  • Non-radiographic axial spondyloarthritis of occipito-atlanto-axial region: M45A1
  • Non-radiographic axial spondyloarthritis of cervical region: M45A2
  • Non-radiographic axial spondyloarthritis of cervicothoracic region: M45A3
  • Cervical instability: M53.2*
  • Whiplash: S13.4
  • Cervical radiculopathy: M47.81*, M50*, M54.1*
  • Degenerative disc disease and disorders: M50*, S13.0*
  • Stenosis: M47.2*, M48.0*, M99.7*
  • Sprain: S13.1*, S13.2*, S13.4*, S13.5*
  • Strain: S16*
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