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MEX5: Hammer Toe Outcome

Measure ID

MEX5

MIPS Reporting Option

Traditional MIPS

Measure Title

Hammer Toe Outcome

Measure Description:

Percentage of patients with a who have a lesser toe deformity (hammer and claw toes) causing pain that receive an intervention and have clinically significant reduction in pain as a result of that intervention

Denominator:

All patients aged 18 and older on the date of initial encounter for one of the diagnosis codes associated with this measure. (Q66.89, M20.41, M20.42, M20.5x1, M20.5x2, M20.61, M20.62)
AND
Are provided an intervention to address their pain
Interventions include:
Surgical Interventions
Shoe wear modifications
Orthotics
Physical Therapy
AND
Report a level of pain of 3 or more on a scale of 1 – 10 on the initial visit

Numerator:

Patients in the denominator received an intervention as defined in the denominator.
DEFINITION
Pain Evaluation – Consists of a documented evaluation of patient reported pain level utilizing a standardized pain scale.
Performance Met Numerator
(MEX5A)Pain Decreased Significantly (second value equal to or less than 50% of the initial value) (BMC Med. 2017; 15: 35.
Published online 2017 Feb 20. doi: 10.1186/s12916-016-0775-3)
OR
(MEX5B)Performance Not Met Numerator 4 Pain level not documented
(MEX5C)Performance Not Met Numerator 5 Pain not decreased by 50% or more.

Denominator Exclusions:

(MEX5D) Clinician documented that the patient was not an eligible candidate for evaluation of lesser toe pain. For example, the patient has condition that would not allow them to accurately respond to a pain level exam or the patient has previously documented peripheral neuropathy with loss of protective sensation.
(MEX5E) Patients who have been prescribed Opioids
(MEX5F) Patient who fail to return for follow up (a 2nd visit)

Denominator Exceptions: (MEX5G) Clinician documented that patient was not an eligible candidate for treatment of hammer toe 

Numerator Exclusions: None

NQF ID N/A

NQS Domain: Effective Clinical Care

High Priority: Yes

Measure Type: Outcome

Includes Telehealth : No

Meaningful Measure Area: Functional Outcomes

Meaningful Measure Area Rationale: Reduction of pain aligns with patient goals

Inverse Measure: No

Proportional Measure: Yes

Continuous Variable Measure: No

Ratio Measure: No

If Continuous Variable and/or Ratio is chosen, what would be the range of the score(s)?: N/A

Number of performance rates to be submitted: 1

Performance Rate Description(s): Proper Evaluation of a Hammer Toe is critical to proper treatment. Percentage of patients who are evaluated for a hammer toe and experience a decrease in pain

Overall Performance Rate: 1st Performance Rate

Care Setting: Ambulatory Care: Clinician Office/Clinic

Risk Adjusted Status : No

Care Setting : Ambulatory Care: Clinician Office / Clinic