Measure 131 – Pain Assessment and Follow-Up

Please note: Measure 131 has been removed from the MIPS CQM measure set for the 2020 performance year.

Audit Criteria

When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 131 requires documentation that a patient was given a pain assessment using a standardized tool on each visit AND documentation that the clinician developed a follow-up plan when pain is present.

This documentation may be found in the patient’s medical record, AAOE Empower (if using the survey functionality available to you in Empower), and/or in another survey database. The relevant document(s) should be made available to the auditor for the patient requested.


What survey instrument is required?

The measure requires the use of a survey instrument that has been normed and validated for the population in which it is used. Some examples include (instruments with a * are included in AAOE Empower):

  • Brief Pain Inventory
  • Faces Pain Scale
  • McGill Pain Questionnaire
  • Multidimensional Pain Inventory
  • Neuropathic Pain Scale
  • Numeric Rating Scale
  • Oswestry Disability Index
  • Roland Morris Disability Questionnaire
  • Verbal Descriptor Scale
  • Verbal Numeric Rating Scale
  • Visual Analog Scale*
  • PROMIS[1]


[1] AAOE Empower contains the short form PROMIS 10 survey which measures pain and functional status. This instrument may be used for completing this measure.