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 460 requires documentation of a patient’s change in back pain (pre-operative to post-operative) following a lumbar fusion surgery.
This documentation may be found in the patient’s medical record. The relevant document should be made available to the auditor for the patient requested.
What needs to be submitted?
This measure has two submission criteria. The first is the traditional numerator/denominator data most other measures require. The second is the average change in back pain among all eligible patients as measured by the visual analog scale. The denominator for the second submission type is the performance met population calculate for submission criteria one (i.e. the number of patients that were administered the VAS on the appropriate timeline).
What does the auditor need to see?
Your auditor will need to see evidence that the visual analog scale was administered to the patient in question no greater than three pre-operatively and no greater than 20 weeks post-operatively.