Back Pain Measure Group Patient Visit Form

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1 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, TE: Patients with applicable back surgical procedure codes do not need to have an E&M code. 1. Patient ID 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. 2. Patient Visit Date The visit date you are reporting on must occur within the Reporting Period. 3. Patient Age The patient must be between the ages of 18 through 79 to qualify for the Back Pain measure group. 4. Patient Gender 5. Is the patient Hispanic or Latino origin or descent? 6. What is the patient s race? American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White Skip the question 7. What is the patient s primary insurance? Medicare Medicaid Commercial Self Pay Other/Unknown 8. If commercial insurance, what insurance carrier does the patient have? Page 1 of 6

2 9. 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)? 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: Diagnosis of Back Pain Back-related Surgical Procedure 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 Please choose the applicable diagnosis code for Back Pain. See definition section below: What if my patient s diagnosis code isn t listed? Not listed 12. Was the diagnosis code selected above billed to Medicare for a visit that occurred within the Reporting Period? Page 2 of 6

3 13. Please choose the applicable code for the back-related surgical procedure. See definition section below: What if my patient s surgical procedure code isn t listed? Not listed 14. Was the procedure code selected above billed to Medicare for a procedure that occurred within the Reporting Period? 15. Did the initial visit for this episode of Back Pain occur within the Reporting Period? See definition section below: Episode and Initial Visit If No, the patient is not eligible for the Back Pain measure group. 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)? 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)? 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? 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? Page 3 of 6

4 20. Is there evidence in the medical record that a complete structural examination was done? 21 Is there evidence in the medical record of a diagnosis of somatic dysfunction related to back pain? 22 Is there evidence in the medical record that osteopathic manipulative treatment was done? 23 If yes, is there evidence in the medical record of assessment of pain before OMT using any quantitative pain rating scale? 24 If yes, is there evidence in the medical record of assessment of pain after OMT using any quantitative pain rating scale? 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. Page 4 of 6

5 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 Page 5 of 6

6 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 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 Page 6 of 6

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