| Setting |
CMS Program |
Developed by |
Measure ID |
Title |
Year/ Description/ Benchmark (when available) |
| Outpatient | QPP - MIPS (*)
| US Wound Registry
| CDR1
| Outcome measure: Adequate Off-loading of Diabetic Foot Ulcers at each visit, appropriate to location of ulcer | Percentage of visits in which diabetic foot ulcers among patients aged 18 years and received adequate off-loading during a 12-month reporting period, stratified by location of the ulcer. As a benchmark, among eligible providers reporting this measure, per visit off-loading of DFUs is now achieved 59 % of the time
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry | CDR2 | Outcome measure: Diabetic Foot Ulcer (DFU) Healing or Closure
| Percentage of diabetic foot ulcers among patients age 18 or older that have achieved healing or closure
within 6 months, stratified by the Wound Healing Index. Healing or closure is defined as complete
epithelialization without drainage or the need for a dressing over the closed ulceration, although venous
compression would still be required.
|
| Outpatient |
QPP - MIPS (*)
|
US Wound Registry |
CDR3 |
Process measure: Plan of Care Creation for Diabetic Foot Ulcer (DFU) and Venous Leg Ulcer (VLU) not Achieving 30% Closure at 4 Weeks after undergoing treatment with CTP
|
2019 measure; A plan of care needs to be created for patients that fail to achieve 30% of wound closure within 4 weeks of the application of the first CTP, and will include review of whether appropriate usual care has been implemented as well as whether further CTP applications are indicated
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry and the Undersea and Hyperbaric Medical Society (UHMS)
| CDR8 | Appropriate use of hyperbaric oxygen therapy for patients with diabetic foot ulcer | Percent of diabetic foot ulcers graded stage 3 or higher on the Wagner Grading System for Diabetic Foot Infections that received HBOT appropriately, among diabetic foot ulcers receiving HBOT during the reporting period. Prior to receiving HBOT patients must have met the following criteria: Have a diabetic foot ulcer that has not achieved 30% closure after four weeks of treatment, adequate offloading of the diabetic foot ulcer at each visit for four weeks of treatment, vascular screening performed, measurement of BMI with follow-up MIPS #128. As a benchmark, In 2000, the OIG published a report called, “Hyperbaric Oxygen Therapy, Its Use and Appropriateness,” in which it estimated that 32% of payments for HBOT were paid in error ($14.2 million that year). A 2013 retrospective study found that 60% of the diabetic foot ulcers treated with HBOT in the study sample were Wagner Grade 2, confirming that Medicare coverage guidelines of reserving HBOT for Wagner 3 and above were not being followed.[5]
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry
| CDR9 | Appropriate use of Cellular and/or Tissue Based Product (CTP) in diabetic foot ulcers (DFUs) or venous leg ulcer (VLUs) among patients 18 years or older
| 2019 measure; Percent of patients 18 or older with venous or diabetic foot ulcer who receive cellular and/or tissue based products (CTPs) appropriately. Appropriate Use of CTPs for a DFU or VLU is defined as use that adheres to Medicare coverage policy regarding the total number of applications over a specific timeframe. Regional Medicare Administrative Carrier (MAC) policies differ but using the most restrictive Local Coverage Determination (LCD), appropriate use is defined as: No more than 10 applications per wound, CTP applications do not continue if the wound is unchanged in size or larger in size after 4 weeks have elapsed from the first application, CTP applications do not continue once the wound is 0.5 cm2 or smaller. Prior to application of a CTP, patient should undergo vascular assessment to exclude ischemia, control bioburden, and debride necrotic material, as well as provide other appropriate basic interventions such as compression of a venous ulcer or offloading of a diabetic foot ulcer. Currently the benchmark rate is only 23%.
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry and the Undersea and Hyperbaric Medical Society (UHMS) | USWR16 | Outcome measure: Major Amputation in Wagner Grade 3, 4, or 5 DFUs Treated with HBOT
| 2019 measure; Percentage of ulcers of patients aged 18 years or older with a diagnosis of a Wagner Grade 3, 4, or 5
diabetic foot ulcer (DFU) whose ulcer has an outcome of major amputation 6 months after completion
of a course of HBOT, stratified by the Wound Healing Index.
|
Outpatient
| QPP - MIPS (*)
| US Wound Registry
| USWR22
| Patient Reported Nutritional Assessment and Intervention Plan in Patients with Wounds and Ulcers
| The percentage of patients aged 18 years and older with a diagnosis of a wound or ulcer of any type who self-report nutritional screening with a validated tool (such as the Self-MNA® by Nestlé) as well as food insecurity assessment, AND for whom the clinician provides an intervention plan within the 12-month reporting period.
|
Outpatient
| QPP - MIPS (*)
| US Wound Registry
| USWR23
| Non Invasive Arterial Assessment of patients with lower extremity wounds or ulcers for determination of healing potential
| Percentage of patients aged 18 years or older with a non healing lower extremity wounds or ulcers that underwent a non-invasive arterial assessment once in a 12 month period, stratified by ABI, perfusion pressure, or oximetry. Data from the USWR indicates that fewer than 10% of patients with chronic non-healing leg ulcers undergo any type of vascular assessment (ABI, transcutaneous oximetry or skin perfusion pressure) even at hospital based outpatient wound centers.
|
Outpatient
| QPP - MIPS (*)
| US Wound Registry
| USWR24
| Patient Reported Experience of Care: Wound Outcome
| All eligible patients with wounds or ulcers who completed of Wound Outcome Questionnaire who showed 10% improvement at discharge or transfer to another site of care during the 12 month reporting period.
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry
| USWR27
| Assessment of Nutritionally At-Risk Patients for Malnutrition and Development of Nutrition Recommendations/Interventions by a Registered Dietitian Nutritionist
| Percentage of patients age 18 years and older who are nutritionally at-risk that have documented nutrition intervention recommendations by a registered dietitian nutritionist or clinical qualified nutrition professional if identified with moderate or severe malnutrition as part of a nutrition assessment. A study by Sherry et. al (2017) demonstrated that only 65% of patients who screened positive for malnutrition risk received any referral to a nutrition professional or an order for nutritional support.[6]
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry
| USWR28
| Obtaining Preoperative Nutritional Recommendations from a Registered Dietitian Nutritionist (RDN) in Nutritionally At-Risk Surgical Patients
| Percentage of patients age 18 years and older who have undergone a surgical procedure and were identified to be at-risk for malnutrition based on a malnutrition screening OR who were referred to a registered dietitian nutritionist or clinically qualified nutrition professional and have a preoperative nutrition assessment which was documented in the medical record along with documentation of any recommended nutrition interventions.
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry, SCG Health
| SCG2 | Outcome Assessment for Patients Prescribed Ankle Orthosis for Ambulation and Functional Improvement
| 2019 measure; Percentage of of patients 18 years and older who had at least two medical visits during the performance period, and for whom an ankle orthosis was prescribed to assist with ambulation AND report a significant improvement in ambulation and function with the orthosis using a standardized tool within the performance period |
| Outpatient | QPP - MIPS (*)
| US Wound Registry, SCG Health
| SCG3 | Outcome Assessment for Patients Prescribed Foot Orthosis for Ambulation and Functional Improvement
| 2019 measure; Percentage of patients 18 years and older with a deformity of the foot or forefoot, who had at least two
medical visits during the performance period, and for whom a foot orthosis was prescribed to assist with
ambulation AND report a significant improvement in ambulation and function with the orthosis using a
standardized tool within the reporting period
|
| Outpatient | QPP - MIPS (*)
| US Wound Registry, SCG Health
| SCG5 | Improvement in Quality of Life from Partial Foot, Prosthetics
| 2019 measure; Percentage of patients 18 years and older with a prescription f or a partial foot prosthetic to assist with ambulation whose health related quality of life (HRQoL) was assessed during at least two visits during the performance period AND whose health related quality of life score stayed the same or improved |
| Outpatient | QPP - MIPS (*)
| Medicare | MIPS1 | Diabetes: Hemoglobin A1c Poor Control
| Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement
period
|
Outpatient
| QPP - MIPS (*)
| Medicare | MIPS 126 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy - Neurological Evaluation
| Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological
examination of their lower extremities within 12 months
|
| Outpatient | QPP - MIPS (*)
| Medicare | MIPS 127 | Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention - Evaluation of Footwear
| Percentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper
footwear and sizing
|
Outpatient
| QPP - MIPS (*)
| Medicare
| MIPS 128
| Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
| Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter
|
Outpatient
| QPP - MIPS (*)
| Medicare | MIPS 131
| Pain Assessment and Follow-Up
| 2019 measure. 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
|
