Measure 155: Falls: Plan of Care (SOAP 1.0)

Nearly 1 in 4 older adults (65+) reported falling in the last year, causing more than 8 million injuries (according to the CDC). This makes Physical and Occupational Therapists an integral part of the public health continuum addressing the risk of falls in older adults. In this article we’ll cover when and how to document Measure 155: Falls: Plan of Care.

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.

Who can report this measure?

PTs and OTs can report on this measure.

Patient Qualifications

Patient age (65 or older)
Patient has a “positive” screening for future fall risk/documentation of two or more falls within the past year or any fall with injury within the past year
Visit type: Initial Evaluation or Re-Evaluation

When do I report on this measure?

During each eligible visit type within the performance period when a patient’s fall risk is reported as “positive”.

Measure Requirements

The Plan of Care must include balance, strength, and gait training and include one of the following options:

Documentation that balance, strength, and gait training/instructions were provided, OR
Referral to an exercise program, which includes at least one of the three components: balance, strength, or gait, OR
Referral to physical therapy

Measure Specification

For more information on Measure 155, please see the Measure Specification Guide.

Measure Reporting in WebPT

On the Subjective tab in the Medical History section, document if the patient has had a history of falls. Click Yes to document the patient's history of falls.
In the section that appears below, document if the patient has fallen 2 or more times (or 1 time with injury) in the last 12 months, and your assessment of the patient's risk for falls.
On the Objective Tab, select the Falls: Plan of Care link from Measure 155 in the MIPS Measure Tests section.
Falls: Plan of Care will appear in the Special Tests section. Select the Yes radio button to reveal the additional options.
Select Yes for all of the following radio buttons: Gait Training and Balance/Strength. You must complete each field to meet the measure requirements.
When finished documenting, validate the selection in the Keet.

Keet: Reporting Selections

In Keet, you’ll need to add this activity to the patient’s Care Plan.

Note: The data in Keet is collated and sent to CMS. The data in the WebPT EMR supports what is submitted to CMS in the event of an audit.

Use the MIPS Badge on the patient chart or the MIPS tab in the note to open Keet.
Log in to Keet.

Note: After logging in to Keet, keep the tab open to remain logged in to Keet to streamline this step while documenting on future appointments. Keet may log users out after three hours of inactivity.
In Keet, navigate to the patient’s Episode of Care that corresponds with the case in the WebPT EMR.
Click Add Activity.
Click Measure 155: Falls: Plan of Care to add to the patient’s Care Plan.
In the Care Plan, click the ellipses (...) icon in the Action column.
Click Complete.
Select the option that best describes your supporting documentation.
Click Submit.