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QCDR Measure Specification


Measure ID: FOTO1

Title of measure: Functional Status Change for Patients with Neck Impairments

Measure Description: This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14 years+ with neck impairments. The change in FS is assessed using the Neck FS PROM. In order to fairly measure performance between providers, the measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, the individual clinician level, and the clinic level to assess quality.

National Quality Strategy (NQS) domain: Effective Clinical Care

Measure type: patient-reported outcome (PRO)

Meaningful Measure Area: Patient-reported functional outcomes

National Quality Forum (NQF) number: (leave blank until we get endorsement)

Denominator description: All patients aged 14 years and older who initiated an episode of rehabilitation therapy, medical or chiropractic care (as defined by the following CPT codes: 97161, 97162, 97163 for physical therapy or 97165, 97166, 97167 for occupational therapy or 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215 for physician or 98940, 98941, 98942, 98943 for chiropractic care) for neck impairments of an orthopedic nature including cervical (neck) pain, radiculopathy, strain, sprain, stenosis, myelopathy, spondylosis, or disc disorders as defined by one or more of the following ICD-10 codes: G54.2  G54.8  G55     G89.29 M05.69 M05.79 M05.89 M06.08 M06.28 M06.38 M06.88            M08.08 M08.1  M08.28 M08.48 M08.88 M08.98 M11.08 M11.18 M11.28 M11.88            M12.08 M12.18 M12.28 M12.48 M12.58 M12.88 M13.0  M13.88 M14.68 M14.88            M15.0  M15.3  M15.4  M15.8  M15.9  M19.90 M19.91 M19.92 M19.93 M24.08            M24.10 M24.28 M24.80 M24.9  M25.28 M25.30 M25.50 M25.60 M25.78 M25.80            M25.9  M32.10 M32.19 M32.8  M32.9  M40.03 M40.12 M40.13 M40.202            M40.203          M40.292          M40.293          M41.112          M41.113            M41.122          M41.123          M41.22 M41.23 M41.41 M41.42 M41.43 M41.52            M41.53 M41.82 M41.83 M42.01 M42.02 M42.03 M42.11 M42.12 M42.13 M43.01            M43.02 M43.03 M43.11 M43.12 M43.13 M43.21 M43.22 M43.23 M43.3  M43.4            M43.5X2          M43.5X3          M43.6  M43.8X1          M43.8X2          M43.8X3            M45.1  M45.2  M45.3  M46.01 M46.02 M46.03 M46.21 M46.22 M46.23 M46.31            M46.32 M46.33 M46.41 M46.42 M46.43 M46.51 M46.52 M46.53 M46.81 M46.82            M46.83 M46.91 M46.92 M46.93 M47.11 M47.12 M47.13 M47.21 M47.22 M47.23            M47.811          M47.812          M47.813          M47.891          M47.892            M47.893          M48.01 M48.02 M48.03 M48.11 M48.12 M48.13 M48.21 M48.22            M48.23 M48.31 M48.32 M48.33 M48.41-           M48.42-           M48.43-            M48.51-           M48.52-           M48.53-           M48.8X1          M48.8X2            M48.8X3          M49.81 M49.82 M49.83 M50.00 M50.01 M50.020          M50.021            M50.022          M50.023          M50.03 M50.10 M50.11 M50.120          M50.121            M50.122          M50.123          M50.13 M50.20 M50.21 M50.220          M50.221            M50.222          M50.223          M50.23 M50.30 M50.31 M50.320          M50.321            M50.322          M50.323          M50.33 M50.80 M50.81 M50.820          M50.821            M50.822          M50.823          M50.83 M50.90 M50.91 M50.920          M50.921            M50.922          M50.923          M50.93 M53.0  M53.1  M53.2X1          M53.2X2            M53.2X3          M53.81 M53.82 M53.83 M54.11 M54.12 M54.13 M54.2  M54.81            M54.89 M54.9  M62.830          M62.838          M62.89 M63.88 M65.28 M65.88            M66.18 M70.88 M70.98 M71.48 M71.58 M71.88 M79.12 M79.7  M80.08-            M80.88-           M81.0  M81.6  M81.8  M85.88 M89.8X8          M93.28 M93.88            M93.98 M95.3  M96.1  M99.01 M99.11 M99.21 M99.31 M99.41 M99.51 M99.61            M99.71 M99.81 Q76.1  Q76.2  Q76.3  Q76.411          Q76.412          Q76.413            Q76.49 R25.2  R29.3  R29.898          R29.91 R51     S12.000-         S12.001-            S12.01-           S12.02-           S12.030-         S12.031-         S12.040-            S12.041-         S12.090-         S12.091-         S12.100-         S12.101-            S12.110-         S12.111-         S12.112-         S12.120-         S12.121-            S12.130-         S12.131-         S12.14-           S12.150-         S12.151-            S12.190-         S12.191-         S12.200-         S12.201-         S12.230-            S12.231-         S12.24-           S12.250-         S12.251-         S12.290-            S12.291-         S12.300-         S12.301-         S12.330-         S12.331-            S12.34-           S12.350-         S12.351-         S12.390-         S12.391-            S12.400-         S12.401-         S12.430-         S12.431-         S12.44-            S12.450-         S12.451-         S12.490-         S12.491-         S12.500-            S12.501-         S12.530-         S12.531-         S12.54-           S12.550-            S12.551-         S12.590-         S12.591-         S12.600-         S12.601-            S12.630-         S12.631-         S12.64-           S12.650-         S12.651-            S12.690-         S12.691-         S12.8- S12.9- S13.0- S13.100-         S13.101-            S13.110-         S13.111-         S13.120-         S13.121-         S13.130-            S13.131-         S13.140-         S13.141-         S13.150-         S13.151-            S13.160-         S13.161-         S13.170-         S13.171-         S13.180-            S13.181-         S13.20-           S13.29-           S13.4- S13.5- S13.8- S13.9-            S14.2- S14.8- S14.9- S16.1- S16.2- S16.8- S16.9- S19.80-           S19.89-            T85.850-          Z82.61


Numerator description: 

The numerator is the number of a provider’s (clinic’s or clinician’s) patient care episodes that completed an episode of care and met or exceeded the risk-adjusted predicted Residual Change Score.


The completion of an episode of care is indicated by by a re-evaluation CPT 97164 for physical therapy, or 97168 for occupational therapy, or a Discharge Status G-Code (G=xxxx) identifying the close of the episode of care for the same neck impairment identified at admission.


The Residual Change Score is defined as the difference between the Actual and Predicted Change Scores where 

  • The Actual Score is the patient’s Functional Status (FS) Score,
  • The Actual Change Score is the change in the patient’s FS score from Admission to Discharge, and
  • The Predicted Change Score is the risk-adjusted prediction of FS change. (Please see the Comments section of the related JIRA/MUC submission for details of the Risk-adjustment component.)


Calculating the Residual - Example

Actual Score at Admission       45

Actual Score at Discharge       60

Actual Change Score (Discharge minus Admission)    +15

Predicted Change Score          +10

Residual (Actual Change minus Predicted)      +5                                                            


Numerator Options are

Performance Met (The Residual Change Score is equal to or greater than 0) and

Performance Not Met (The Residual Change Score is less than  0 or patient did not complete the measure and reason not given or reason does not match the exclusion or exception criteria.) 


Performance may be calculated on 3 levels:

  1. Patient Level: For the individual patient episode, the patient’s Actual FS scores relative to the risk-adjusted predicted.
  2. Clinician Level: The average of the Residuals for patient care episodes managed by a clinician (individual provider) over a 12-month time period.
  3. Clinic Level: The average of the Residuals for patient care episodes managed by a group of clinicians within a clinic over a 12-month time period.


Denominator exceptions:

1) Patient refused to participate at admission and/or discharge (G=xxxx)

2) Patient unable to complete the Neck FS PROM at admission or discharge due to cognitive deficit, visual deficit, motor deficit, language barrier, or low reading level, and a suitable proxy/recorder is not available. (G=xxxx)

3) Patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown) (G=xxxx)

4) Medical reasons (e.g., scheduled for surgery or hospitalized) (G=xxxx)


Denominator exclusions: None


Is the measure risk adjusted? Yes


Number of performance rates required for measures: 1


High priority status: Outcome


Traditional vs. inverse measure: No


Proportional, continuous variable, outcome, and ratio measure indicator: Proportional