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MIPS Quality Measures for Speech-Language Pathologists

Claims-Based Quality Reporting for Medicare Part B Services

Speech-language pathologists (SLPs) who see Medicare Part B (outpatient) beneficiaries and exceed the low-volume threshold for claims may be required to participate in the Merit-Based Incentive Payment System (MIPS). Use the 2021 MIPS Eligibility Decision Tree [PDF] to determine if you are required to participate.

The Centers for Medicare and Medicaid Services (CMS) requires MIPS-eligible providers to report at least six quality measures for a minimum of 60% of the eligible Medicare patient visits to earn an incentive payment and avoid future penalties. However, SLPs do not have six measures they are eligible to report; therefore when applicable, SLPs must report on all five measures that are available. They are:

See also: Explore 2021 MIPS Measures and Activities

How to Report Quality Measures

  1. Complete a CMS-1500 form [PDF] as you normally would for reimbursement, using diagnosis (ICD-10-CM) and procedure (CPT) codes.
  2. If the patient encounter for that claim meets the criteria for quality reporting, add the appropriate quality data code (QDC) on the claim.
  3. The QDC you select will either be a MIPS-specific G-code or CPT II code (CPT II codes may also require a modifier), as outlined in the measure specifications. QDCs are reported in the following areas of the claim form:
    • Box 21: ICD-10-CM (diagnosis) codes
    • Box 24D:
      • CPT (procedure) code for the service provided
      • QDC code on the line following the CPT code for the applicable service
      • CPT II code modifier, in the modifier section on the same line as the CPT II code (If the QDC is a G-code, a modifier is not needed)

See also: 2021 Part B Claims Submission Quick Start Guide [PDF]

Keys to Reporting Success!

  • Identify the patient population (e.g., age, clinical condition).
  • Identify the CPT code that triggers reporting.
  • Report the QDC (episode/visit) during the 12-month reporting period (January-December) when the applicable CPT code is reported.
    • Complete the quality action and report the QDC that represents performance met for each eligible encounter, whenever appropriate.
  • Document everything (for example, the standardized tool used and the follow-up plan).
  • Report multiple QDCs with associated CPT codes for an encounter on the same claim, not separately.
  • Do not leave the QDCs off claims when reporting is required. You can’t resubmit corrected claims for MIPS reporting purposes.

MIPS Quality Measures for SLPs

All information included here is summarized from CMS’ Medicare Part B claims measure specifications and supporting documents [ZIP]. SLPs can use use the search or filter functions within the CMS MIPS measures and activities tool to view and download full CMS measure specifications. See the appendix of the 2021 Part B Claims Submission Quick Start Guide [PDF] for an example of how measures are reported on a claim form.

Key

Performance met

You completed and documented the quality action fully for that eligible encounter. You will receive points toward your overall score in the quality category.

Denominator exception 

You did not perform the quality action for that eligible encounter because there was a documented medical reason the patient was not eligible for the quality action. You will receive partial points toward your overall score in the quality category.

Performance not met

You did not perform the quality action for that eligible encounter (for example, you forgot to perform the action or you forgot to report the quality code on the claim form). You will not receive any points and will lower your overall score in the quality category.

To avoid a 9% penalty in 2023 based on 2021 reporting, a minimum of 60% of eligible Medicare claims must include a quality code identified with 

Performance met

.

Measure 130: Documentation of Current Medications in the Medical Record

Key Terms to Know

Current Medications: Medications the patient is presently taking including all prescriptions, over-the-counter, herbal and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route 

Route: Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical)

Not Eligible (Denominator Exception): A patient is not eligible if if there is documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status).

Reporting Criteria Patients 18 years and older with the following procedure code(s) for every billed encounter.
CPT Codes 92507, 92508, 92526, 92626, 97129

Quality Data Codes (QDCs)

Pick one QDC to report on the same claim as the applicable CPT code.

G8427

Performance met

Eligible clinician attests to documenting in the medical record that they obtained, updated, or reviewed the patient’s current medications.

The list must include all known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements and must contain the medication’s name, dosage, frequency, and route of administration

G8430

Denominator exception 

Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g. patient is in an urgent or emergent medical situation) 

G8428

Performance not met

Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given


Measure 134: Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Key Terms to Know

Screening: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.

Standardized Depression Screening Tool: A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to:

Follow-Up Plan: Documented follow-up for a positive depression screening must include one or more of the following: 

  • Additional evaluation for depression 
  • Suicide Risk Assessment
  • Referral to a practitioner who is qualified to diagnose and treat depression
  • Pharmacological interventions
  • Other interventions or follow-up for the diagnosis or treatment of depression

Not Eligible (Denominator Exclusion): To use QDC G9717 (screening not completed), the patient must have one or more of the following ICD-10-CM diagnoses related to depression or bipolar disorder: F01.51, F32.0-F32.5, F32.89, F32.9, F33.0-F33.3, F33.40-F33.42, F33.8, F33.9, F34.1, F34.81, F34.89, F43.21, F43.23, F53, O90.6, O99.340-O99.343, O99.345, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4, F31.5, F31.60-F31.64, F31.70-F31.78, F31.81, F31.89, F31.9 (See the complete ICD-10-CM list for more detail on the range of codes).

ASHA Note: These diagnoses should be assigned by a physician or mental health professional and documented in the medical record.

Not Eligible (Denominator Exception): To use QDC G8433 (screening not completed, reason documented), one or more of the following must be documented in the medical record:

  • Patient refuses to participate
  • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
  • Situations where the patient’s functional capacity or motivation to improve may impact the accuracy of results of standardized depression assessment tools (for example, certain court appointed cases or cases of delirium)
Reporting Criteria Patients 12 years and older with the following procedure code(s), reported a minimum of once per calendar year, per patient.
CPT Codes

96105, 96112, 96125, 92625

Quality Data Codes (QDCs)

Pick one QDC to report on the same claim as the applicable CPT code.

Reporting Criteria

G8431

Performance met

Screening for depression is documented as being positive and a follow-up plan is documented 

G8510 

Performance met

Screening for depression is documented as negative, a follow-up plan is not required  

G8433

Denominator exception

Screening for depression not completed, documented reason

G9717

Denominator exclusion

Documentation stating the patient has an active diagnosis of depression or has a diagnosed bipolar disorder

G8432

Performance not met

Depression screening not documented, reason not given 

G8511  

Performance not met

Screening for depression documented as positive, follow-up plan not documented, reason not given 


Measure 181: Elder Maltreatment Screening and Follow Up Plan

Key Terms to Know

Screen for Elder Maltreatment: An elder maltreatment screen should include assessment and documentation of one or more of the following components: physical abuse, emotional or psychological abuse, neglect (active or passive), sexual abuse, abandonment, financial or material exploitation, and unwarranted control.

Physical Abuse: Infliction of physical injury by punching, beating, kicking, biting, burning, shaking, or other actions that result in harm.

Psychological Abuse: Willful infliction of mental or emotional anguish by threat, humiliation, isolation, or other verbal or nonverbal conduct.

Neglect: Involves attitudes of others or actions caused by others-such as family members, friends, or institutional caregivers-that have an extremely detrimental effect upon well-being.

Active Neglect: Behavior that is willful or when the caregiver intentionally withholds care or necessities. The neglect may be motivated by financial gain or reflect interpersonal conflicts.

Passive Neglect: Situations where the caregiver is unable to fulfill his or her care giving responsibilities as a result of illness, disability, stress, ignorance, lack of maturity, or lack of resources.

Note: Self-neglect is a prevalent form of abuse in the elderly population. Screening for self-neglect is not included in this measure. Resources for suspected self-neglect are listed under "Reporting Resources" below.

Sexual Abuse: Forcing of undesired sexual behavior by one person upon another against their will who are either competent or unable to fully comprehend and/or give consent. This may also be called molestation.

Elder Abandonment: Desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.

Financial or Material Exploitation: Taking advantage of a person for monetary gain or profit.

Unwarranted Control: Controlling a person’s ability to make choices about living situations, household finances, and medical care.

Follow-Up Plan: Must include a documented report to state or local Adult Protective Services (APS) or the appropriate state agency. Note: APS does not have jurisdiction in all states to investigate maltreatment of patients in long-term care facilities. In those states where APS does not have jurisdiction, APS may refer the provider to another state agency such as the state facility licensure agency for appropriate reporting.

Not Eligible (Denominator Exception): A patient is not eligible if one or more of the following reasons is documented:

  • Patient refuses to participate and has reasonable decisional capacity for self-protection
  • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
Reporting Criteria Percentage of patients 65 years and older, reported a minimum of once a year when the following procedure code(s) are billed.
CPT Codes

92610, 92521, 92522, 92523, 92524, 92610, 96112, 96125, 96105

Quality Data Codes (QDCs)

Pick one QDC to report on the same claim as the applicable CPT code.

G8733

Performance met

Elder maltreatment screen documented as positive AND a follow-up plan is documented

G8734

Performance met

Elder maltreatment screen documented as negative, follow-up is not required

G8535

Denominator exception

Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter

G8941

Denominator exception

Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible for follow-up plan at the time of the encounter

G8536

Performance not met

No documentation of an elder maltreatment screen, reason not given

G8735

Performance not met

Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given
Reporting Resources

Federal reporting: In addition to state requirements, some types of providers are required by federal law to report suspected maltreatment. For example, nursing facilities certified by Medicare and/or Medicaid are required to report suspected maltreatment to the applicable State Survey and Certification Agency.

For state-specific information to report suspected elder maltreatment, including self-neglect, the following resources are available:

Measure 182: Functional Outcome Assessment

Key Terms to Know

Standardized Tool: A tool that has been normed and validated. Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS), Disabilities of the Arm, Shoulder and Hand (DASH), and Western Ontario and McMaster University Osteoarthritis Index Physical Function subscale (WOMAC-PF).

Functional Outcome Assessment: Patient completed questionnaires designed to measure a patient's limitations in performing the usual human tasks of living and to directly quantify functional and behavioral symptoms.

Current (Functional Outcome Assessment): A patient having a documented functional outcome assessment utilizing a standardized tool and a care plan if indicated within the previous 30 days.

Functional Outcome Deficiencies: Impairment or loss of function related to musculoskeletal/neuromusculoskeletal capacity, may include but are not limited to: restricted flexion, extension and rotation, back pain, neck pain, pain in the joints of the arms or legs, and headaches.

Care Plan: A care plan is an ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. These may include observations, goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused on one or more of the patient’s health care problems. Care plans may also be known as a treatment plan.

Not Eligible (Denominator Exception): A patient is not eligible if one or more of the following reason(s) is documented at the time of the encounter:

  • Patient refuses to participate
  • Patient unable to complete questionnaire
  • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status
Reporting Criteria Percentage of visits for patients 18 years and older documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies. It must be reported at every visit to which it applies during the 2020 reporting period.
CPT Codes 92610, 92611, 92612

Quality Data Codes (QDCs)

Pick one QDC to report on the same claim as the applicable CPT code.

G8539

Performance met

Functional outcome assessment documented as positive using a standardized tool AND a care plan based, on identified deficiencies on the date of the functional outcome assessment, is documented

G8542

Performance met

Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required

G8942

Performance met

Functional outcome assessment using a standardized tool is documented within the previous 30 days and a care plan, based on identified deficiencies on the date of the functional outcome assessment, is documented

G8540

Denominator exception

Functional outcome assessment not documented as being performed, documentation the patient is not eligible for a functional outcome assessment using a standardized tool at the time of the encounter

G9227

Denominator exception

Functional outcome assessment documented, care plan not documented, documentation the patient is not eligible for a care plan at the time of the encounter

G8541

Performance not met

Functional outcome assessment using a standardized tool not documented, reason not given

G8543

Performance not met

Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented, reason not given

Measure 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

This measure contains three submission criteria which aim to identify patients who were screened for tobacco use (submission criteria 1), patients who were identified as tobacco users and who received tobacco cessation intervention (submission criteria 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (submission criteria 3).  

Key Terms to Know

Tobacco Use: Includes any type of tobacco

Tobacco Cessation Intervention: Includes brief counseling (3 minutes or less), and/or pharmacotherapy. Note: For the purpose of this measure, brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) qualifies. Written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify. 

Submission Criteria 1: Patients Who Were Screened for Tobacco Use at Least Once
Reporting Criteria All patients 18 years and older, reported a minimum of once a year when the following procedure code(s) are billed.
CPT Codes 92521, 92522, 92523, 92524

Quality Data Codes (QDCs)

Pick one QDC to report on the same claim as the applicable CPT code. If you provided a screening and intervention during the same encounter, see Submission Criteria 2 or 3.

G9902 

Performance met

Patient screened for tobacco use and identified as a tobacco user

G9903

Performance met

Patient screened for tobacco use and identified as a tobacco non-user

G9904 

Denominator exception

Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) 

G9905 

Performance not met

Patient not screened for tobacco use, reason not given

Note: Submit this QDC when a patient is screened for tobacco use and tobacco status is unknown. 

Submission Criteria 2: All Patients Who Were Identified as a Tobacco User and Who Received Tobacco Cessation Intervention
Reporting Criteria All patients 18 years and older who were screened for tobacco use and identified as a tobacco user, reported a minimum of once a year when the following procedure code(s) are billed.
CPT Codes 92521, 92522, 92523, 92524

Quality Data Codes (QDCs)

Pick one QDC from Submission Criteria 2 and report with QDC G9902 from Submission Criteria 1 if the patient has been identified as a tobacco user.

G9906 

Performance met

Patient identified as a tobacco user received tobacco cessation intervention (counseling and/or pharmacotherapy)

Note: You must report two G-codes (G9902 and G9906) on the claim form for this quality action.

G9907 

Denominator exception

Documentation of medical reason(s) for not providing tobacco cessation intervention (e.g., limited life expectancy, other medical reason) 

Note: You must report two G-codes (G9902 and G9907) on the claim form when the quality action is not performed for documented medical reasons.

G9908 

Performance not met

Patient identified as tobacco user did not receive tobacco cessation intervention (counseling and/or pharmacotherapy), reason not given

Note: You must report two G-codes (G9902 and G9908) on the claim form when the quality action is not performed and there is no reason given. 

Submission Criteria 3: All Patients Who Were Screened for Tobacco Use and, if Identified as a Tobacco User Received Tobacco Cessation Intervention, or Identified as a Tobacco Non-User

Note: Unlike other measures reported using only G-codes, Submission Criteria 3 for measure 226 is reported using G-codes or CPT II codes that could include modifiers. If a modifier is required, it should be placed with the CPT II code in the modifier section in box 24D of the CMS-1500 claim form.

Reporting Criteria All patients 18 years and older, reported a minimum of once a year when the following procedure code(s) are billed. 
CPT Codes 92521, 92522, 92523, 92524

Quality Data Codes (QDCs)

Pick one QDC to report on the same claim as the applicable CPT code. Remember to append the appropriate modifier for a CPT II code, when indicated.

4004F

Performance met

Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user

1036F 

Performance met

Current tobacco non-user

4004F with 1P

Denominator exception

 

Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason)

Note: Append modifier 1P to CPT II code 4004F

G9909

Denominator exception

Documentation of medical reason(s) for not providing tobacco cessation intervention if identified as a tobacco user (e.g., limited life expectancy, other medical reason)

4004F with 8P

Performance not met

Tobacco screening not performed or tobacco cessation intervention not provided, reason not otherwise specified

Note: Append modifier 8P to CPT II code 4004F

Other Resources

Contact Information

Quality Payment Program Help and Support
Phone: 1-866-288-8292                          
TTY: 1-877-715-6222  

Note: To avoid security violations, do not include personal identifying information, such as a Social Security Number or TIN, in written inquiries to the QPP help desk.

American Speech-Language-Hearing Association
E-mail: reimbursement@asha.org

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