Draft spinal stenosis measures 082807 for public comment

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• Publié par: Esli
• Nombre de lectures: 78
• Langue: English

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American Academy of Orthopaedic Surgeons (AAOS), American Academy of Physical Medicine and Rehabilitation (AAPMR), American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS), North American Spine Society (NASS), Physician Consortium for Performance Improvement ® , National Committee for Quality Assurance   Degenerative Lumbar Spinal Stenosis Physician Performance Measurement Set   DRAFT August 2007   Degenerative Lumbar Spinal Stenosis Work Group  (specialty)  Robert Haralson III, MD, MBA (Co-Chair) (Orthopaedic Surgery) William C. Watters, III, MD (Co-Chair) (Orthopaedic Surgery)    Chris Alexander, III, MD, MACRhe, FACP Catherine H. MacLean, MD, PhD (Health Plan) (Rheumatology) Tom Marr, MD (Health Plan) Peter Carmel, MD (Neurosurgery) Daniel Mazanec, MD (Rheumatology) Anthony Delitto, PhD, PT, FAPTA (Physical Therapy) Donald R. Murphy, DC (Chiropractic Medicine) Richard Deyo, MD (Internal Medicine) Yuri Nakasato, MD (Geriatric Rheumatology) Thomas J. Gilbert, MD, MPP (Radiology) Daniel K. Resnick, MD, MS (Neurosurgery) Ken Grossman, MD (Employer) Frank Salvi, MD, MS (Physical Medicine and Andrew Haig, MD (Physical Medicine and Rehabilitation)  Rehabilitation) Donald D. Storey, MD (Health Plan) Donald J. Iverson, MD (Neurology) Michael Wasylik, MD, PA (Orthopaedic Surgery) Michael G. Kaiser, MD (Neurosurgery) David A. Wong, MD, MSc (Orthopaedic Surgery) Jon Lurie, MD (Internal Medicine)    Staff: American Academy of Orthopaedic Surgeons (AAOS) Jill Hughes, MA   American Academy of Physical Medicine and Rehabilitation (AAPMR) Lisa Kaplan, JD   American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Rachel Groman, MPH   North American Spine Society (NASS) Belinda Duszynski   American Medical Association Heidi Bossley, MSN, MBA Karen S. Kmetik, PhD Joseph Gave   National Committee for Quality Assurance Sarah Sampsel, MPH Phil Renner, MBA   Consultants Timothy F. Kresowik, MD Rebecca A. Kresowik  1

Physician Performance Measures (Measures) and related data specifications have been developed by the American Medical 2 Association (AMA) in collaboration with the Physician Consortium for Performance Improvement (the Consortium) and the National Committee for Quality Assurance (NCQA).   These performance Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.   The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA, (on behalf of the Consortium) or NCQA. Neither the AMA, NCQA, Consortium nor its members shall be responsible for any use of the Measures.   THE MEASURES AND SPECIFICATIONS ARE PROVIDED “AS IS” WITHOUT WARRANTY OF ANY KIND.   © 2007 American Medical Association and National Committee for Quality Assurance. All Rights Reserved.   Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA, NCQA, the Consortium and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT®) or other coding contained in the specifications.   CPT® contained in the Measures specifications is copyright 2006 American Medical Association.

Purpose of Measures: These clinical performance measures, developed by the American Academy of Orthopaedic Surgeons (AAOS), American Academy of Physical Medicine and Rehabilitation (AAPMR), American Association of Neurological Surgeons (AANS)/Congress of Neurologi ® cal Surgeons (CNS), North American Spine Society (NASS), the Physician Consortium for Performance Improvement (Consortium), and the National Committee for Quality Assurance (NCQA), are  designed for individual quality improvement. Unless otherwise indicated, the measures are also appropriate for accountability if appropriate methodological, statistical, and implementation rules are achieved.   The draft performance measures included in this measurement set are intended to provide feedback to physicians on whether the diagnosis of degenerative lumbar spinal stenosis was made accurately, whether treatment decisions were made based on the severity of symptoms and with patient input, and how patients responded to the selected treatment. Except as noted in the rationale sections of this document, no data are currently available regarding gaps in care for the diagnosis and treatment of degenerative lumber spinal stenosis. Limited data are available regarding variations in care. Implementation of these measures will provide a first step in assessment of where current gaps and variations in care exist and what additional components of care should be included in the next iteration of this measurement set.    The Consortium measure development methodology requires measures to be based primarily on a national, widely- accepted clinical practice guideline or evidence base, with a strong preference for guidelines that include ratings of evidence and strength of recommendation and for evidence from randomized controlled trials. Exceptions have been made for non-research-based processes (eg, symptom assessment) when a clear linkage can be made to evidence- based care (eg, treatment for heart failure). The Consortium also recognizes that for many areas of patient care, evidence-based guidelines are not available. The Measures Development, Methodology, and Oversight Advisory Committee of the Consortium is currently drafting recommendations on the evidence base required for Consortium measures, including the potential use of expert opinion in measure development.    The draft measures for spinal stenosis were derived from evidence-based clinical guidelines, specifically the North American Spine Society’s Clinical Guideline on Degenerative Lumbar Spinal Stenosis. This guideline includes a rating of the evidence within a scheme for grading recommendations, as described at the end of this document. For most of the draft spinal stenosis measures, the Work Group determined that although the verbatim guideline statements do not provide a direct basis for the measures, a clear linkage can be made between the clinical processes measured and the subsequent, evidence-based care recommended. The Work Group therefore considers the NASS guideline recommendations to comprise an acceptable and sufficient evidence base for these measures.    We invite comment on whether the measures address key areas of importance and potential need for improvement and whether the evidence base cited  for  the measures is sufficient.   In addition, Measure #7: Assessment of Patient Response to Surgical Treatment cannot be implemented in the Centers for Medicare and Medicaid Services Physicians Quality Reporting Initiative (PQRI) program as the program is designed currently. This measure requires that the assessment be completed both before and after surgery, which would require the reporting of a CPT Category II code at the post-operative visit. It is common for physicians who perform the surgery to bill using a global fee and thus do not submit a claim for the follow-up visit. For this reason, the data elements required for this measure cannot be captured and submitted as needed for the PQRI program.   Accountability Measures: # 1. History and Physical on or Before the Date of Diagnosis # 2. Documentation of Neurogenic Symptoms Prior to Surgical Intervention # 3. Documentation of Neurogenic Symptoms Prior to Epidural Steroid Injections (ESI) # 5. Assessment of Patient Response to Medical and Interventional Treatment # 6. Assessment of Patient Function and Pain Status Prior to Surgical Treatment # 7. Assessment of Patient Response to Surgical Treatment # 8. Shared Decision Making    © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 3 CPT ®  Copyright 2006 American Medical Association

Quality Improvement Measure: # 4. Use of Contrast-enhanced Fluoroscopy for Epidural Steroid Injections   Intended Audience and Patient Population: These measures are designed for use by physicians and for calculating reporting or performance measurement at the individual physician level. The Consortium also encourages the use of these measures by eligible health professionals, where appropriate. When existing hospital-level or plan-level measures are available for the same measurement topics, the Consortium attempts to harmonize the measures to the extent feasible.    These measures are designed for physicians managing the ongoing care of patients aged 50 years and older with degenerative lumbar spinal stenosis. Although this diagnosis occurs in ages less than 50 years, this measurement set includes only patients over the age of 50 years to limit other potential concomitant diagnoses or conditions.     Measure Specifications  The Consortium seeks to specify measures for implementation using multiple data sources, including paper medical record, administrative (claims) data, and particular emphasis on Electronic Health Record Systems (EHRS). Draft specifications to report on these measures for degenerative lumbar spinal stenosis using administrative (claims) data are included in this document. We have identified codes for these measures, including ICD-9 and CPT (Evaluation & Management Codes, Category I and where Category II codes would apply). Specifications for additional data sources, including EHRS, will be fully developed at a later date.   Measure Exclusions: For process measures, the Consortium provides three categories of reasons for which a patient may be excluded from the denominator of an individual measure:   •  Medical reasons  Includes: - not indicated (absence of organ/limb, already received/performed, other) - contraindicated (patient allergic history, potential adverse drug interaction, other)   •   Patient reasons  Includes: - patient declined - economic, social, or religious reasons - other patient reasons   •   System reasons  Includes: - resources to perform the services not available - insurance coverage/payor-related limitations - other reasons attributable to health care delivery system   These measure exclusion categories are not available uniformly across all measures; for each measure, there must be a clear rationale to permit an exclusion for a medical, patient, or system reason. The exclusion of a patient may be reported by appending the appropriate modifier to the CPT Category II code designated for the measure:   •   Medical reasons: modifier 1P •   Patient reasons: modifier 2P •  System reasons: modifier 3P   Although this methodology does not require the external reporting of more detailed exclusion data, the Consortium recommends that physicians document the specific reasons for exclusion in patients’ medical records for purposes of © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 4 CPT ®  Copyright 2006 American Medical Association

optimal patient management and audit-readiness. The Consortium also advocates the systematic review and analysis of each physician’s exclusions data to identify practice patterns and opportunities for quality improvement. For example, it is possible for implementers to calculate the percentage of patients that physicians have identified as meeting the criteria for exclusion.   Please refer to documentation for each individual measure for information on the acceptable exclusion categories and the codes and modifiers to be used for reporting.   For outcome measures, the Consortium specifically identifies all acceptable reasons for which a patient may be excluded from the denominator. Each specified reason is reportable with a CPT Category II code designated for that purpose.   The Consortium continues to evaluate and likely will evolve its methodology for handling exclusions as it gains experience in the use of the measures. The Consortium welcomes comments on its exclusions methodology.   Data Capture and Measure Calculation The Consortium intends for physicians to collect data on each patient eligible for a measure. Feedback on measures should be available to physicians by patient to facilitate patient management and in aggregate to identify opportunities for improvement across a physician's patient population.   Measure calculations will differ depending on whether a rate is being calculated for performance or reporting purposes.      The method of calculation for performance follows these steps:  first, identify the patients who meet the eligibility  criteria for the denominator (PD); second, identify which of those patients meet the numerator criteria (A); and third, for those patients who do not meet the numerator criteria, determine whether an appropriate exclusion applies and subtract those patients from the denominator (C). (see examples below)     The methodology also enables implementers to calculate the rates of patient exclusions and to further analyze both low and high rates, as appropriate (see examples below).   The method of calculation for reporting differs.  One program which currently focuses on reporting rates is the Centers  for Medicare and Medicaid Services (CMS) Physician Quality Reporting Initiative (PQRI). Currently, under that program design, there will be a reporting denominator determined solely from claims data (CPT and ICD-9), which in some cases result in a reporting denominator that is much larger than the eligible population for the performance denominator. Additional components of the reporting denominator are explained below.    The components that make up the numerator for reporting include all patients from the eligible population for which the physician has reported, including: the number of patients who meet the numerator criteria (A), the number of patients for whom valid exclusions apply (C) and also the number of patients who do not meet the numerator criteria (D).   These components, where applicable, are summed together to make up the inclusive reporting numerator. The calculation for reporting will be the reporting numerator divided by the reporting denominator. (see examples below).   Examples of calculations for reporting and performance are provided for each measure.   Calculation for Performance  For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator, and Denominator Exclusions.   Numerator (A) Includes: Number of patients meeting numerator criteria     © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 5 CPT ®  Copyright 2006 American Medical Association

  Performance Denominator (PD) Includes: Number of patients meeting criteria for denominator inclusion   Denominator Exclusions (C) Include: Number of patients with valid medical, patient or system exclusions (where applicable; will differ by measure)   Performance Calculation   A (# of patients meeting numerator criteria)    PD (# patients in denominator) – C (# patients with valid denominator exclusions)    It is also possible to calculate the percentage of patients excluded overall, or excluded by medical, patient, or system reason where applicable:      Overall Exclusion Calculation   C (# of patients with a   ny valid exclusion)    PD (# patients in denominator)          RO   Exclusion Calculation by Type C m 1  ( e # d   i p c a al t   i r e e n a ts s   o w n i ) t   h  C 2 p   a ( t # i   e p n a t  ti r e e n a t s s o  w n) it   h   C s 3   y ( s # t   e p m at   i r e e n a t s s  o w n i ) t   h       PD (# patients in denominator) PD (# patients in denominator) PD (# patients in denominator)   Calculation for Reporting  For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator   Reporting Numerator includes each of the following components, where applicable. (There may be  instances where there are no patients to include in A, C, D, or E).   A.  Number of patients meeting additional denominator criteria (for measures where true denominator cannot be determined through ICD-9 and CPT Category I coding alone) AND numerator criteria   C.  Number of patients with valid medical, patient or system exclusions (where applicable; will differ by measure)   D. Number of patients not meeting numerator criteria and without a valid exclusion   E.  All other patients not meeting additional denominator criteria (for measures where true denominator cannot be determined through ICD-9 and CPT Category I coding alone)           © Me ® asures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 6 CPT Copyright 2006 American Medical Association 

    Reporting Denominator (RD) Includes: RD. Denominator criteria (identifiable through ICD-9 and CPT Category I coding)     Reporting Calculation   A(# of patients meeting additional denominator criteria AND numerator criteria) + C(# of patients with valid exclusions) + D(# of patients NOT meeting numerator criteria) + E(# of patients not meeting additional denominator criteria)   RD (# of patients    in denominator) © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. CPT ®  Copyright 2006 American Medical Association 7

   DRAFT Degenerative Lumbar Spinal Stenosis Measure #1: History and Physical on or Before the Date of Diagnosis     This measure may be used as an Accountability measure   Clinical Performance Measure Numerator: Patients who have a history and physical documented on or before the date of diagnosis   Medical record must include all of the following: Patient history; Assessment of prior treatment and response; Pain assessment; Functional status, including assessment of activity-related leg pain; AND Physical or neurological examination   Denominator: All patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis   Denominator Exclusions: None     Measure: Percentage of patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis who have a history and physical documented on or before the date of diagnosis   The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure:   Lumbar spinal stenosis should be considered in older patients presenting with a history of severe lower extremity pain which improves or resolves with sitting and postural abnormalities on physical examination such as a wide-based gait. Physical findings adding to this consideration include an abnormal Romberg test, thigh pain exacerbated with extension and neuromuscular deficits. Patients whose pain is not made worse with walking have a low likelihood of stenosis. (Grade I) (NASS) 1      Rationale: The patient assessment of pain and function informs treatment decisions and provides a baseline for assessing improvement in symptoms. Information about the patient’ss ymptoms, history, duration and description of symptoms, prior episodes and response to therapy are important in the care of degenerative lumbar spinal stenosis. In addition, the physical exam is an integral component of identifying and confirming the source and mechanism of degenerative lumbar spinal stenosis and provides the physician with the information necessary to determine the next steps for treatment.   Data capture and calculations:   Calculation for Performance  For performance purposes, this measure is calculated by creating a fraction with the following components: Numerator, Denominator.   Performance Numerator (A) Includes:   •   Patients who have a history and physical documented on or before the date of diagnosis    © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 8 CPT ®  Copyright 2006 American Medical Association

Performance Denominator (PD) Includes:   •   Patients aged 50 years and older AND •   A diagnosis of degenerative lumbar spinal stenosis   Performance Calculation     A (# of patients meeting measure criteria)        PD (# of patients in denominator)       Components for this measure are defined as: A # of patients who have a history and physical documented on or before the date of diagnosis   PD # of patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis   Calculation for Reporting    For reporting purposes, this measure is calculated by creating a fraction with the following components: Reporting Numerator and Reporting Denominator   Reporting Numerator includes each of the following instances:    A. Patients who have a history and physical documented on or before the date of diagnosis    D. Patients who do not have a history and physical documented on or before the date of diagnosis   Reporting Denominator (RD) Includes:   •   Patients aged 50 years and older AND •   A diagnosis of degenerative lumbar spinal stenosis   Reporting Calculation       A(# of patients meeting numerator criteria) + D(# of patients NOT meeting numerator criteria)         RD (# of patients in denominator)       Components for this measure are defined as: A # of patients who have a history and physical documented on or before the date of diagnosis  D # of patients who do not have a history and physical documented on or before the date of diagnosis   RD # of patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis     © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. CPT ®  Copyright 2006 American Medical Association 9

Measure Specifications – Measure #1: History and Physical on or Before the Date of Diagnosis Measure specifications for data sources other than administrative claims will be developed at a later date.   A.   Administrative claims data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible population/denominator criteria.   (Note: The specifications listed below are those needed for performance calculation.)    Denominator (Eligible Population): All patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis   ICD-9 diagnosis codes: 724.02  DNA CPT E/M codes: 99201-99205 (Office or Other Outpatient Services New Patient) 99211-99215 (Office or Other Outpatient Services New Patient) 99241-99245 (Office Consultations) 97001 (Physical therapy evaluation) 97002 (Physical therapy re-evaluation) 98940 ((Chiropractic manipulative treatment (CMT); spinal, one to two regions) 98941 ((Chiropractic manipulative treatment (CMT); spinal, three to four regions) 98942 ((Chiropractic manipulative treatment (CMT ); spinal, five regions)   Denominator Exclusion: None    Numerator: Patients who have a history and physical documented on or before the date of diagnosis   •   Report the CPT Category II code (in development) designated for this numerator: XXXXF   B. Electronic Health Record System (in development)    C. Paper Medical Record (in development)      © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 10 CPT ®  Copyright 2006 American Medical Association

 DRAFT Degenerative Lumbar Spinal Stenosis Measure #2: Documentation of Neurogenic Symptoms Prior to Surgical Intervention     This measure may be used as an Accountability measure Clinical Performance Measure       Numerator: Patients who have documentation of radiculopathy or neurogenic intermittent claudication at the time of surgery   Denominator: All patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis who had surgery for spinal stenosis   Denominator Exclusions: Documentation of medical reason(s) for not documenting radiculopathy or neurogenic intermittent claudication at the time of surgery (eg, primary reason for surgery was not degenerative lumbar spinal stenosis)     Measure: Percentage of patients aged 50 years and older with a diagnosis of degenerative lumbar spinal stenosis who had surgery for spinal stenosis who had documentation of radiculopathy or neurogenic intermittent claudication at the time of surgery  The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines and represent the evidence base for the measure:   In patients with severe symptoms of lumbar spinal stenosis, decompressive surgery alone is effective approximately 80% of the time. (Grade C) (NASS) 1      In patients with moderate to severe symptoms of lumbar spinal stenosis, surgery is more effective than medical/interventional treatment. (Grade C) (NASS) 1      In patients with mild to moderate symptoms of lumbar spinal stenosis, medical/interventional treatment is effective approximately 70% of the time. (Grade C) (NASS) 1      In patients with severe symptoms of lumbar spinal stenosis, decompressive surgery alone is effective 1 about 80% of the time and medical/interventional treatment alone is effective about 33% of the time. (Grade C) (NASS)   Rationale: Lumbar spinal stenosis describes a clinical syndrome of buttock or lower extremity pain, which may occur with or without back pain, associated with diminished space available for the neural and vascular elements in the lumbar spine. Symptomatic lumbar spinal stenosis has certain characteristic provocative and palliative features. Provocative features include exercise or positionally-induced neurogenic claudication. Palliative features commonly include symptomatic relief with forward flexion, sitting and/or recumbency. (NASS) 1   This measure is intended to assess whether a surgical intervention is provided to those patients for whom it is most appropriate – those who are experiencing radiculopathy or neurogenic intermittent claudication.   The medical reason exclusion has been included to allow patients for whom this measure does not apply to be removed from the denominator (ie, the primary reason for the surgery was not for degenerative lumbar spinal stenosis but rather since that diagnosis was a contributing factor it has been included in the medical record or administrative data).       © Measures including specifications © 2007 American Medical Association and National Committee for Quality Assurance. 11 CPT ®  Copyright 2006 American Medical Association