MIPS 2023: Available Quality Measures

WebPT members can report on 2 types of Quality Measures: Patient Reported Outcomes(PRO) and Process Measures. Review the article below for a list of available measures, and the system they’re documented in.

Note:

Quality measures must be documented in both WebPT and Keet. The data in Keet is collated and sent to CMS during the MIPS submission period, and the data in the WebPT EMR supports what is sent to CMS.
Previously, Members reporting for MIPS with WebPT selected which measures they wanted to collect data for during the setup process. This step has been eliminated. You can now select which MIPS measures to collect data for on a visit by visit basis.

Process Measures

Process measures show what providers do to improve the health of patients. These measures are typically generally accepted recommendations for clinical practice.

SOAP 1.0

Measure Name	Patient Age	Visit Type	Required Diagnosis?
Measure 126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy: Neurological Evaluation	18+	Initial Evaluation OR Re-Evaluation	Yes
Measure 127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear	18+	Initial Evaluation OR Re-Evaluation	Yes
Measure 128: Body Mass Index (BMI) Screening and Follow-Up	18+	Initial Evaluation	No
Measure 130: Documentation and Verification of Current Medications in the Medical Record	18+	Initial Evaluation, Re-Evaluation, OR Discharge Summary	No
Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan	12+	Initial Evaluation	No
Measure 155: Falls: Plan of Care	65+	Initial Evaluation OR Re-Evaluation	No
Measure 181: Elder Maltreatment Screen and Follow-Up Plan	65+	Initial Evaluation	No
Measure 182: Functional Outcome Assessment	18+	Initial Evaluation, Re-Evaluation, and Discharge Summary	No
Measure 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	18+	Initial Evaluation OR Re-Evaluation	No

Patient Reported Outcome Measures

Outcome measures require the patient to complete 2 Patient Reported Outcome(PRO) questionnaires. The difference in score between the Initial Evaluation and a subsequent visit constitutes the Minimum Clinically Important Difference (MCID)—after a risk adjustment formula is applied.

Measure Name	Associated PRO	MCID
IROMS 11: Functional Status Change for Patients with Knee Functional Status Deficit	Knee Outcome Survey (KOS)	10
IROMS 13: Functional Status Change for Patients With Lower Extremity Functional Status Deficit	Lower Extremity Functional Scale (LEFS)	9
IROMS 15: Functional Status Change for Patients With Neck Functional Status Deficit	Neck Disability Index (NDI)	7.5
IROMS 17: Functional Status Change for Patients With Low Back Functional Status Deficit	Modified Low Back Pain Disability Questionnaire (MDQ)	6
IROMS 19: Functional Status Change for Patients With Upper-limb Functional Status Deficit	Quick Disability or Arm, Shoulder and Hand Score (QDASH)	8
HM7: Functional Status Change for Patients With Lower Extremity Functional Status Deficit	Dizziness Handicap Inventory (DHI)	18