2016 PQRS Measure #131: Pain Assessment and Follow-Up

DESCRIPTION

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

INSTRUCTIONS

This measure is to be reported each visit occurring during the reporting period for patients seen during the reporting period. There is no diagnosis associated with this measure. This measure may be reported by eligible professionals who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding. The documented follow up plan must be related to the presence of pain, example: “Patient referred to pain management specialist for back pain” or “Return in two weeks for re-assessment of pain”.

DENOMINATOR

All visits for patients aged 18 years and older

AND

Patient encounter during the reporting period (CPT): 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 97001, 97002, 97003, 97004, 97532, 98940, 98941, 98942, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, D7140, D7210, G0101, G0402, G0438, G0439

NUMERATOR

Patient visits with a documented pain assessment using a standardized tool(s) AND documentation of a follow-up plan when pain is present

Numerator Note: The standardized tool used to assess the patient’s pain must be documented in the medical record (exception; A provider may use a fraction such as 5/10 for Numeric Rating Scale without documenting this actual tool name when assessing pain for intensity)

DEFINITIONS
Pain Assessment
- Documentation of a clinical assessment for the presence or absence of pain using a standardized tool is required. A multi-dimensional clinical assessment of pain using a standardized tool may include characteristics of pain; such as: location, intensity, description, and onset/duration.

Standardized Tool
– An assessment tool that has been appropriately normalized and validated for the population in which it is used. Examples of tools for pain assessment, include, but are not limited to: Brief Pain Inventory (BPI), Faces Pain Scale (FPS), McGill Pain Questionnaire (MPQ), Multidimensional Pain Inventory (MPI), Neuropathic Pain Scale (NPS), Numeric Rating Scale (NRS), Oswestry Disability Index (ODI), Roland Morris Disability Questionnaire (RMDQ), Verbal Descriptor Scale (VDS), Verbal Numeric Rating Scale (VNRS), and Visual Analog Scale (VAS).

Follow-Up Plan
– A documented outline of care for a positive pain assessment is required. This must include a planned follow-up appointment or a referral, a notification to other care providers as applicable OR indicate the initial treatment plan is still in effect. These plans may include pharmacologic and/or educational interventions.

Not Eligible
– A patient is not eligible if one or more of the following reason(s) is documented:
• Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example, cases where pain cannot be accurately assessed through use of nationally recognized standardized pain assessment tools
• Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

Options
Pain Assessment Documented as Positive AND Follow-Up Plan Documented
Pain assessment documented as positive using a standardized tool AND a follow-up plan is documented
OR
Pain Assessment Documented as Negative, No Follow-Up Plan Required
Pain assessment using a standardized tool is documented as negative, no follow-up plan required
OR
Pain Assessment NOT Documented Patient not Eligible
Pain assessment NOT documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool
OR
Pain Assessment Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible
Pain assessment documented as positive, follow-up plan not documented, documentation the patient is not eligible
OR
Pain Assessment not Documented, Reason not Given
No documentation of pain assessment, reason not given
OR
Pain Assessment Documented as Positive, Follow-Up Plan not Documented, Reason not Given
Pain assessment documented as positive using a standardized tool, follow-up plan not documented, reason not given



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Pain Assessment and Follow-Up

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