6.
What is the patient’s race?
Please complete the form below for 20 unique patients meeting the patient sample criteria for the measure group. For the Back Pain Measure Group,
patients you enter that have a diagnosis of back pain, must have a valid E&M code during the Reporting Period, though you are not required to enter
this code. Valid E&M codes are: 97001, 97002, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 NOTE: Patients with applicable
back surgical procedure codes do not need to have an E&M code.
Use the Patient ID that is automatically assigned, or enter an identifier that is meaningful to your practice. Keep a record of this identifier in case you need to make edits.
1.
Patient ID
The visit date you are reporting on must occur within the Reporting Period .
2.
Patient Visit Date
The patient must be between the ages of 18 through 79 to qualify for the Back Pain measure group.
3.
Patient Age
4.
Patient Gender
5.
Is the patient Hispanic or Latino origin or descent?
Self Pay Other/Unknown
Native Hawaiian or Pacific Islander
7.
What is the patient’s primary insurance?
YES NO
White
Skip the question American Indian or Alaska Native
Asian
Black or African American
Medicare Medicaid Commercial
8.
If commercial insurance, what insurance carrier does the patient have?
Back Pain Measure Group Patient Visit Form
11.
Please choose the applicable diagnosis code for Back Pain.
Diagnosis of Back Pain Back-related Surgical Procedure
See definition section below: What if my patient’s diagnosis code isn’t listed?
F
721.3F
721.41F
721.42F
721.90F
722.0F
722.10F
722.11F
722.2F
722.30F
722.31F
722.32F
722.39F
722.4F
722.51F
722.52F
722.6F
722.70F
722.71F
722.72F
722.73F
722.80F
722.81F
722.82F
722.83F
722.90F
722.91F
722.92F
722.93F
723.0F
724.00F
724.01F
724.02F
724.09F
724.2F
724.3F
724.4F
724.5F
724.6F
724.70F
724.71F
724.79F
738.4F
738.5F
739.3F
739.4F
756.12F
846.0F
846.1F
846.2F
846.3F
846.8F
846.9F
847.2F
Not listed YES NO9.
Is the patient a Medicare Part B Fee-For-Service (FFS) beneficiary
(includes Railroad Retirement Board and Medicare Secondary Payer; does
not include Medicare Advantage beneficiaries)?
If “Diagnosis of Back Pain” is selected, skip questions 13 and 14 and move on to question 15 If “Back-related Surgical Procedure” is selected, skip questions 11 and 12 and move on to question 13
10.
In order to be eligible for the Back Pain Measure Group, the patient must
have either a diagnosis of back pain or a back-related surgical procedure
code. Please select the type of code you wish to enter for this patient:
YES NO
12.
Was the diagnosis code selected above billed to Medicare for a visit that
occurred within the Reporting Period?
See definition section below: What if my patient’s surgical procedure code isn’t listed?
F
22210F
22214F
22220F
22222F
22224F
22226F
22532F
22533F
22534F
22548F
22554F
22556F
22558F
22585F
22590F
22595F
22600F
22612F
22614F
22630F
22632F
22818F
22819F
22830F
22840F
22841F
22842F
22843F
22844F
22845F
22846F
22847F
22848F
22849F
63001F
63003F
63005F
63011F
63012F
63015F
63016F
63017F
63020F
63030F
63035F
63040F
63042F
63043F
63044F
63045F
63046F
63047F
63048F
63055F
63056F
63057F
63064F
63066F
63075F
63076F
63077F
63078F
63081F
63082F
63085F
63086F
63087F
63088F
63090F
63091F
63101F
63102F
63103F
63170F
63172F
63173F
63180F
63182F
63185F
63190F
63191F
63194F
63195F
63196F
63197F
63198F
63199F
63200F
Not listed13.
Please choose the applicable code for the back-related surgical procedure.
YES NO
14.
Was the procedure code selected above billed to Medicare for a
procedure that occurred within the Reporting Period?
YES NO See definition section below: Episode and Initial Visit
If “No,” the patient is not eligible for the Back Pain measure group.
15.
Did the initial visit for this episode of Back Pain occur within the Reporting
Period?
YES NO
16.
Were all five of the following components assessed at the initial visit
to the clinician for an episode of back pain within the reporting year :
pain assessment, functional status, patient history (including notation of
presence or absence of warning signs), assessment of prior treatment
and response, and employment status (see Assessment Requirements)?
YES NO
17.
Is there documentation of a physical exam at the initial visit of this
episode of back pain within the reporting year (see Physical Exam
Requirements)?
YES NO
18.
Is there documentation of advice to maintain or resume normal activities
at the initial visit for this episode of back pain within the reporting year?
NO YES
19.
Is there documentation of advice to the patient against bed rest lasting
four days or longer at the initial visit for this episode of back pain within
the reporting year?
Definitions
What if my patient’s diagnosis code isn’t listed?
The diagnosis code for the patient must be one of those listed in the question. If you have a diagnosis code that is not listed, this patient is not eligible to be reported for the Back Pain measure group.
What if my patient’s surgical procedure code isn’t listed?
The surgical procedure code for the patient must be one of those listed in the question. If you have a procedure code that is not listed, this patient is not eligible to be reported for the Back Pain measure group.
Episode
Patient with back pain who has not been seen or treated for back pain by any practitioner during the 4 months prior to the first clinical encounter with a diagnosis of back pain. If a patient has a four-month period without treatment, and then sees both a primary care physician and a specialist, both visits are considered the initial visit with that clinician. A new episode can either be a recurrence for a patient with prior back pain or a patient with a new onset of back pain. The first clinical encounter after the four months without being seen or treated for back pain is considered the beginning of the new episode.
Initial Visit
First visit to the clinician during an episode of back pain. There can only be one initial visit with each clinician, but there can be more than one initial visit for a patient, if multiple clinicians evaluate or treat the patient for the back pain episode.
Complete structural examination
A complete structural examination must include all of the following three components: Evaluation of AP and lateral curvature of the spine or other bony landmark asymmetries. Evaluation of soft tissue abnormalities including tenderness. Evaluation of range of motion or restrictions thereof.
YES NO
20.
Is there evidence in the medical record that a complete structural
examination was done?
NO YES
21
Is there evidence in the medical record of a diagnosis of somatic
dysfunction related to back pain?
NO YES
22
Is there evidence in the medical record that osteopathic manipulative
treatment was done?
NO YES
23
If yes, is there evidence in the medical record of assessment of pain
before OMT using any quantitative pain rating scale?
NO YES
24
If yes, is there evidence in the medical record of assessment of pain after
OMT using any quantitative pain rating scale?
Assessment Requirements
Pain Assessment
– Must use any of the following assessment tools:
SF-36
Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability Questionnaire
Quebec Pain Disability Scale Sickness Impact Profile Multidimensional Pain Inventory
OR
If none of the above tools are used, documentation of any of the following pain scales is acceptable:
McGill Pain Questionnaire Visual analog scale Brief pain inventory Chronic pain grade Neuropathic pain scale
Numerical rating scale (e.g., pain intensity 1–10)
Verbal descriptive scale (e.g., pt. report: “burning, shooting, stabbing”) Faces pain scale
Functional Status Assessment
– Must use any of the following assessment tools:
SF-36
Oswestry Low Back Pain Disability Questionnaire Roland-Morris Disability Questionnaire
Quebec Pain Disability Scale Sickness Impact Profile Multidimensional Pain Inventory
OR
If none of the above tool are used, there must be documentation that activities of daily living (ADL) were assessed.
Assessment of all the following ADLs must be documented:
Eating Bathing Using the toilet Dressing
Getting up from bed or a chair
Patient History
– Documentation necessary to satisfy assessment for red flags, which can include the following:
Indication/notation of presence or absence of red flags
Notation of specific symptoms that may indicate the presence of red flags (examples noted below) “Red Flags” include:
History of cancer or unexplained weight loss Current infection or immunosuppression Fracture or suspected fracture
Motor vehicle accident or industrial injury with suspicion of fracture Major fall with suspicion of fracture
Cauda equina syndrome or progressive neurologic deficit Saddle anesthesia
Recent onset bladder dysfunction (urine retention, increased frequency, overflow incontinence) Recent onset fecal incontinence (loss of bowel control)
Major motor weakness
Physical Exam Requirements
Physical Examination:
For patients with radicular symptoms, documentation of physical exam must include the following, at a minimum:
Indication of straight leg raise test
AND
Notation of completion of neurovascular exam (a neurovascular exam must include ankle and knee reflexes; quadriceps; ankle and great toe dorsiflexion strength; plantar flexion; muscle strength; motor testing; pulses in lower extremities; and sensory exam)
For patients without radicular symptoms, documentation of physical exam must include the following:
Documentation of straight leg raise, neurovascular exam or clear notation of absense or presence of neurologic deficits
Assessment of Prior Treatment and Response
– If applicable, documentation that patient has been
queried about back pain episode(s), treatment and response. Notation could include the following:
No prior back pain
Diagnosis and dates of back pain reports for the previous two years, or as far back as the patient is able to provide information Report from referring physician with summary of back pain history
Patient report of history and attempted treatments, including diagnostic tests (e.g., imaging)
Employment Status
– Use of either of the following assessment tools will satisfy this requirement:
Sickness Impact Profile Multidimensional Pain Inventory
OR
Variables of an employment assessment can count. These variables must include documentation of the following:
Type of work, including job tasks that may affect back pain management Work status (e.g., out of work, part-time work, work with or without limitations) If patient is not working or limited in work capacity, length of time for work limitations Workers’ compensation or litigation involvement
