Performance Measures
SPINEIQ1: Repeated X-ray Imaging
Percent of patients with neck or low back pain who receive two or more of the same x-ray imaging studies within the reporting period. Note, This measure can not be used for MIPS reporting in 2019. NQS Domain: Patient Safety Measure type: Process
SPINEIQ2: MRI of the Lumbar Spine
Percentage of patients with diagnosis of low back pain receiving MRI in the absence of prior conservative care.
Note, This measure can not be used for MIPS reporting in 2019. NQS Domain: Patient Safety Measure Type: Process
SPINEIQ3: Change in Functional Outcomes
Average percent change in functional outcomes assessment between the first date of a care encounter and each qualifying follow-up assessment during the reporting period for patients aged 18 years and older with a diagnosis of neck or low back pain.
Note, This measure can not be used for MIPS reporting in 2019. NQS Domain: Effective Clinical Care Measure type: Outcome
SPINEIQ4: Change in Pain Intensity
Average percent change in pain intensity between the first date of a care encounter and each subsequent encounter closest to a 14-day interval during the reporting period for patients aged 18 years and older with a diagnosis of neck or low back pain.
Note, This measure can not be used for MIPS reporting in 2019. NQS Domain: Effective Clinical Care Measure type: Outcome
Q109 Osteoarthritis (OA): Function and Pain Assessment
Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain. NQS Domain: Person and Caregiver-Centered Experience and Outcomes Measure type: Process
Q128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter. Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2 NQS Domain: Community/Population Health Process
Q131 Pain Assessment and Follow-Up
Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present. NQS Domain: Communication and Care Coordination Measure type: Process
Q134 Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. NQS Domain: Community/Population Health Measure type: Process
Q154 Falls: Risk Assessment
Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months. NQS Domain: Patient Safety Measure type: Process
Q155 Falls: Plan of Care
Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months. NQS Domain: Communication and Care Coordination Measure type: Process
Q182 Functional Outcome Assessment
Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies. NQS Domain: Communication and Care Coordination Measure type: Process
Q226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. NQS Domain: Community/Population Health Measure type: Process
Q236 Controlling High Blood Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. Effective Clinical Care Intermediate Outcome
Q238 Use of High-Risk Medications in the Elderly
Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported. a. Percentage of patients who were ordered at least one high-risk medication. b. Percentage of patients who were ordered at least two different high-risk medications. NQS Domain: Patient Safety Measure type: Process
Q239 Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents
Percentage of patients ages three to 17 years who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported. – Percentage of patients with height, weight and body mass index (BMI) percentile documentation. – Percentage of patients with counseling for nutrition. – Percentage of patients with counseling for physical activity. NQS Domain: Community/Population Health Measure type: Process
Q281 Dementia: Cognitive Assessment
Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12-month period. NQS Domain: Effective Clinical Care Measure type: Process
Q312 Use of Imaging Studies for Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. Efficiency and Cost Reduction Measure type: Process
Q317 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated. NQS Domain: Community/Population Health Measure type: Process
Q318 Falls: Screening for Future Fall Risk
Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period. NQS Domain: Patient Safety Measure type: Process
Q371 Depression Utilization of the PHQ-9 Tool
Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a four-month period in which there was a qualifying visit. NQS Domain: Effective Clinical Care Measure type: Process
Q402 Tobacco Use and Help with Quitting Among Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user. NQS Domain: Community/Population Health Measure type: Process
Q414 Evaluation or Interview for Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks’ duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record. NQS Domain: Effective Clinical Care Measure type: Process
Q431 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user. NQS Domain: Community/Population Health Measure type: Process