Public Access Survey for 2023 & 2024 MIPS Quality ID #221: Functional Status Change for Patients with Shoulder Impairments
Before you get started:
- It is required that you read and ensure your understanding of the measure specification for this quality measure.To download the measure specification, visit the CMS Quality Payment Program website. Search under MIPS/Explore Measures and Activities and select the Clinical Quality Measure Specifications. CMS requires MIPS measure specifications to be housed on the CMS Quality Payment Program website.
- Hint: make sure you understand how to calculate the Residual Score by reading the Definitions in the Numerator section of the measure specifications.
- Once you understand all details of the measure specifications, access the Public Access Survey below for your patients to take the survey at the time of Initial Evaluation, Progress Evaluations, and Discharge during the relevant episode of care.
Success Tips:
- Before administering the survey to your patients, take a “test” survey for yourself (the clinician) to gain familiarity with what your patients will experience and the location of the scoring results that will appear for your MIPS usage on the last page after each patient completes the patient-facing questions.
- Each time your patient completes the survey, be sure to record the date of survey completion, the Functional Status Score, and the Predicted FS Change This will allow you to calculate the Residual Score as described in the Numerator of the measure specification.
About the Public Access Survey
This Public Access Survey provides computer adaptive test (CAT) administration of the primary (FOTO) patient-reported outcome measure (PROM) and standardized patient questions toward risk adjustment as described in the measure specification. Scoring results and details you need for calculating the corresponding MIPS measure are provided on the last screen of the assessment.
Also provided is an option to administer an alternative (“legacy”) PROM to your patient instead of the primary FOTO PROM. Crosswalk functionality, as described in the measure specification, is included. Further details about crosswalk functionality in Clinical Quality Measures 217-222 and 478 are provided here.
The Public Access Survey is available free of charge for non-commercial uses in the context of individual clinical practice, i.e., patient-level measurement, for purposes of participation in the Centers for Medicare and Medicaid Services’ Merit-based Incentive Payment System (MIPS). For any commercial or other type uses, such as incorporation of the measure components into a product or service, Contact FOTO.
To access the Public Access Survey, you will need to read, understand, and agree to the FOTO Standards of Administration and the Terms and Conditions.
Public Access Survey to Support Quality ID 221 (recommended)
For best user experience, select Public Access Survey to Support Quality ID 221 (recommended) here. This recommended option provides patients with a shorter survey experience, using the FOTO Shoulder CAT (computer adaptive test), and reduced clinician/staff burden with automated score and risk adjusted predicted change score provided on the last page of the survey.
This recommended approach aligns with CMS initiatives toward innovation and leveraging modern science and technology to improve meaningfulness and reduce burden for providers and patients while strengthening data integrity for CMS.
Alternative PROM option
This option allows you to administer the Disabilities of the Arm, Shoulder and Hand (DASH) to your patient instead of the FOTO Shoulder CAT. Using this survey option, the DASH may be used to fulfill the PROM component of this quality measure. Even though the DASH and FOTO Shoulder are different PROMs with different scoring metrics, cross-walked scoring functionality allows clinicians the option to administer the DASH to their patients for use in routine clinical care while reporting this quality measure (ID 221) for MIPS.
Analytic testing results confirmed the accuracy (reliability) and validity of the cross-walking methods and no statistically significant differences in “measure achievement points” as defined by CMS and used in CMS benchmarking deciles for MIPS Quality Benchmarks.
Access the Public Access Survey to Support Quality ID 221 with the DASH as the alternative PROM and with all crosswalk functionality automated here.
Manual Administration, Scoring, and Calculating Option (not recommended)
This option is not recommended because of increased provider and patient burden and risk for error in hand-scoring and calculation steps.
Modal Title
Statistically equivalent score-linking between an IRT-based PROM and a suitable legacy PROM is produced using advanced psychometric methods. The approach results in a cross-walk table that facilitates the conversion of a legacy PROM score to the metric of the IRT-based PROM. Once a legacy score is cross-walked to its equivalent IRT-based PROM score, the corresponding risk adjustment model for the CQM can be applied and the risk-adjusted predicted change score calculated, followed by the calculation of patient-level residual scores (i.e., observed change minus predicted change) from which the “performance met” criterion is applied (residual >=0). Depending on the measurement characteristics of the legacy PROM, an adjustment factor may be applied to the crosswalk-based residuals to balance the rates of performance met to those of the IRT-based PROM.
For access to the PROM short form and scoring table select here. ( For access to applicable crosswalk functionality or risk adjustment coefficients email your request to FOTO
References
1. Albano AD, Rodriguez MC. Statistical equating with measures of oral reading fluency. J of Sch Psych 50 (2012) 43–59.
2. Albano AD. R Package ‘equate’ (Version 2.0-3): Observed-Score Linking and Equating. October 21, 2014.
3. Albano AD. equate: An R Package for Observed-Score Linking and Equating. October 21, 2014.
4. PROsetta Stone Linking Patient-Reported Outcome Measures. https://www.prosettastone.org/. Accessed January 15, 2022.