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 469 requires documentation of a patient’s change in functional status (pre-operative to post-operative) who had 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 functional status among all eligible patients as measured by the Oswestry Disability index. The denominator for the second submission type is the performance met population calculated for submission criteria one (i.e. the number of patients that were administered the ODI on the appropriate timeline).
What does the auditor need to see?
Your auditor will need to see evidence that the Oxford Knee Score was administered to the patient in question no greater than three months pre-operatively and no greater than 15 months post-operatively.