2026 MIPS Measure #182: Functional Outcome Assessment

Percentage of visits for patients aged 18 years and older with 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 within two days of the date of the identified deficiencies.

This measure is to be submitted each denominator eligible visit for patients seen during the performance period. The functional outcome assessment is required to be current as defined in the definition section. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: Patient encounters for this measure conducted via telehealth (including but not limited to encounters coded with GQ, GT, POS 02, POS 10) are allowable. Please note that effective January 1, 2025, while a measure may be denoted as telehealth eligible, specific denominator codes within the encounter may no longer be eligible due to changes outlined in the CY 2024 PFS Final Rule List of Medicare Telehealth Services.

All visits for patients aged 18 years and older

DENOMINATOR NOTE: *Signifies that this CPT Category I code is a non-covered service under the Medicare Part B Physician Fee Schedule (PFS). These non-covered services should be counted in the denominator population for MIPS CQMs.

Patients aged ? 18 years on date of encounter

AND

Patient encounter during the performance period (CPT): 92540, 92541, 92542, 92544, 92546, 92548, 92549, 92605, 92607, 92610, 92611, 92612, 92614, 92616, 96125, 92622, 92626, 97129, 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 98000, 98001, 98002, 98003, 98004, 98005, 98006, 98007, 98008, 98009, 98010, 98011, 98012, 98013, 98014, 98015, 98016, 98940, 98941, 98942, 98943*, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99341, 99342, 99344, 99345, 99347, 99348, 99349, 99350

Visits where patient has a documented current functional outcome assessment using a standardized tool AND a documented care plan based on the identified functional outcome deficiencies within two days of the assessment

FUNCTIONAL OUTCOME ASSESSMENT MEASURE – COMPLETE SUMMARY:

DEFINITION – Standardized Tool:
A normed and validated tool that quantifies pain, musculoskeletal/neuromusculoskeletal, or speech/language capacity. Pain-only tools (e.g., VAS) do NOT qualify.

EXAMPLES OF STANDARDIZED TOOLS (not exhaustive):
- Oswestry Disability Index (ODI)
- Roland Morris Disability Questionnaire (RM/RDQ)
- Neck Disability Index (NDI)
- PROMIS (Patient-Reported Outcomes Measurement Information System)
- DASH (Disabilities of the Arm, Shoulder and Hand)
- EAT-10 (Swallowing Screening Tool)
- Health Partners Hearing Assessment
- Tinetti POMA (Performance Oriented Mobility Assessment)
- WOMAC-PF (Western Ontario and McMaster Osteoarthritis Index Physical Function subscale)
- Berg Balance Test
- Functional Independence Measure
- Mini-Mental State Examination (MMSE)
- Motor-Free Visual Perception Test

NOTE: ODI electronic version no longer free; paper alternative available at no cost.

FUNCTIONAL OUTCOME ASSESSMENT:
Patient-completed questionnaire measuring limitations in performing usual human tasks and quantifying functional/behavioral symptoms.

CURRENT ASSESSMENT:
Documented functional outcome assessment using a standardized tool AND a care plan (if indicated) at a qualifying encounter within the previous 30 days.

FUNCTIONAL OUTCOME DEFICIENCIES (qualify for care plan):
1. Impairment, loss of function, or difficulty with participation in daily activities related to:
- Physical (musculoskeletal, cardiovascular, pulmonary, integumentary)
- Sensory, cognitive, behavioral, or visual/perceptual impairments
OR
2. Impairment or loss of function related to speech and language capacity, including:
- Swallowing, hearing, and/or balance disorders

CARE PLAN:
An ordered assembly of expected/planned activities or actionable elements based on identified deficiencies. May include:
- Observations
- Goals
- Services, appointments, and procedures
- Organized in phases or sessions
- Objective: organize and manage health care activity for the patient
- Also known as a treatment plan

MAGNITUDE OF EFFECTS (Based on Mean Between-Group Differences):

FUNCTION (ODI / RDQ):
- Slight/Small: 5-10 points on ODI | 1-2 points on RDQ
- Moderate: >10-20 points on ODI | >2-5 points on RDQ
- Large/Substantial: >20 points on ODI | >5 points on RDQ

SMD (Standardized Mean Difference) – Function:
- Slight/Small: 0.2-0.5
- Moderate: >0.5-0.8
- Large/Substantial: >0.8

ODI = Oswestry Disability Index; RDQ = Roland Morris Disability Questionnaire

DENOMINATOR EXCEPTIONS (Not Eligible – document at time of encounter):
1. Patient refuses to participate
2. Patient unable to participate in administration of the functional outcome assessment(s)
3. Patient is in an urgent/emergent medical situation where time is of the essence and delay would jeopardize health status

NUMERATOR INSTRUCTIONS:
- Documentation must include identification of the standardized tool used
- Follow-up plan must be provided and discussed with patient during qualifying encounter
- Documentation of follow-up plan can occur up to 2 calendar days AFTER qualifying encounter (per practice/health system policies)
- All services should be documented during or as soon as practicable after the encounter

NUMERATOR NOTE (30-Day Window):
- Intent: Functional outcome assessment tool utilized at minimum every 30 days
- Submission required at each qualifying encounter due to coding limitations
- For visits within 30 days of a previously documented functional outcome assessment, use G8942 for reporting

KEY TAKEAWAYS:
1. Use a validated standardized tool – pain-only tools (VAS) do NOT qualify
2. Assess functional outcomes within the previous 30 days
3. Document a care plan if deficiencies are identified
4. Exceptions must be documented at time of encounter
5. Document tool used; follow-up plan can be documented up to 2 days post-encounter
6. Use G8942 for visits within 30 days of prior assessment
7. Magnitude of effect helps interpret improvement (slight, moderate, large)

Performance Met: Functional outcome assessment documented as positive using a standardized tool AND a care plan based on identified deficiencies is documented within two days of the functional outcome assessment (G8539)

OR

Performance Met: Functional outcome assessment using a standardized tool is documented; no functional deficiencies identified, care plan not required (G8542)

OR

Performance Met: Functional outcome assessment using a standardized tool is documented within the previous 30 days and a care plan, based on identified deficiencies is documented within two days of the functional outcome assessment (G8942)

OR

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(G8540)

OR

Denominator Exception: Functional outcome assessment documented, careplan not documented, documentation the patient is not eligible for a care plan at the time of the encounter (G9227)

OR

Performance Not Met: Functional outcome assessment using a standardized tool not documented, reason not given (G8541)

OR

Performance Not Met: Documentation of a positive functional outcome assessment using a standardized tool; care plan not documented within two days of assessment, reason not given (G8543)

Standardized outcome assessments, questionnaires or tools are a vital part of evidence-based practice. Despite the recognition of the importance of outcomes assessments, questionnaires and tools, recent evidence suggests their use in clinical practice is limited. Utilization of the appropriate outcomes assessment, questionnaires, and tools enhances clinical practice by (1) identifying and quantifying body function and structure limitations, (2) formulating evaluation, diagnosis, and prognosis, (3) forming the plan of care, (4) assisting in evaluating the patient progress towards the goals and validating the benefits of treatment, (5) improving communication between client, clinician, and third party payer, (6) assisting to improve the documentation of care provided (Lesher, et al., 2016; Potter, et al., 2011; Schenk, et al. 2016).

“The use of standardized tests and measures early in an episode of care establishes the baseline status of the patient/client, providing a means to quantify change in the patient's/client's functioning. Outcome measures, along with other standardized tests and measures used throughout the episode of care, as part of periodic reexamination, provide information about whether predicted outcomes are being realized” (American Physical Therapy Association (APTA, 2016).

“Consistent assessment of functional status and capacity, as well as health domains that may contribute to impaired function, can help patients and providers make treatment decisions that align with the patient's values, enhance preprocedure or posthospitalization planning, and prevent use of interventions whose risks could well outweigh their benefits” (High,et al., 2019).

Early in the intervention process, occupational therapists should select outcomes that are valid, reliable, sensitive to change; congruent with client goals and based on their actual or purported ability to predict future outcomes. Outcomes are applied to measure progress and adjust goals and interventions. Results are used to make decisions about future direction of intervention (American Occupational Therapy Association (AOTA), 2020).

“Few outcome measures are routinely used to assess patients with neck pain other than a numeric pain rating scale. A comparison of practice patterns to current evidence suggests overutilization of some measures that have questionable reliability and underutilization of some with better supporting evidence. This practice analysis suggests that there is substantial need to implement more consistent outcome measurement” (MacDermid et al., 2013).

Barriers to use of classification systems and outcome measures were lack of knowledge, too limiting, and time. Classification systems are being used for decision-making in physical therapy practice for patients with lower back pain (LBP). Lack of knowledge and training seems to be the main barrier to the use of classification systems in practice (Davies et al., 2014). Lesher, et al. (2016) noted that Occupational Therapists who use assessment tools may not have understood the tools design or intent leading to over interpretation, under interpretation, or misuse of the tool.

Treatment for musculoskeletal disorders and associated lost wages is on the increase in the U.S. One in every 2 Americans have a musculoskeletal disorder leading to an estimated cost of $213 billion for treatment, care, and lost wages (Bone and Joint Initiative, USA, 2016). Hoy, et al (2014) noted in the Global Burden of Disease Study, musculoskeletal disorders accounted for 6.8% of the total disability –adjusted life years (DALYs).

Of the musculoskeletal disorders, arthritis was noted to be the most common cause of disability with an estimated 51.8 million people experiencing some level of disability from arthritis (Bone and Joint Initiative, USA, 2016). Osteoarthritis of the upper limbs produces higher disability scores and earlier episodes of disability; while osteoarthritis of the knees, hips, and spine worsens with age and causes progressive disability (Montero, et al., 2016). The total cost of treating osteoarthritis is $580.9 billion, an increase of 13 percent since 2000, with an estimated 25 million people losing an average of 11.4 days of work for a total of 290.8 million lost work days (Bone and Joint Initiative, USA, 2016).

While arthritis is considered the most common cause of disability, there are several other musculoskeletal disorders that are prevalent. The U.S. Bureau of Labor Statistics (2015) reported that musculoskeletal disorders had the highest incidence of injury, 31% of cases, which accounted for more than four thousand lost work days, with sprains, strains, and tears being the most commonly reported. Of those injuries, the most commonly affected was the upper extremities, with hands and shoulder injuries accounting for the majority of missed days (U.S. Bureau of Labor Statistics, 2015)

Also, Marik, et al. (2016) noted that half of the population will experience shoulder pain leading to decreased strength and restricted range of motion (ROM) impacting quality of life and limiting involvement in meaningful occupational activities. In addition, Blanchette, et al. (2016) reported that low back pain is one of the leading causes of disability worldwide, one of the most common reasons patients seek medical care, most common occupational disorder, and major cause of lost work days.

“Balance is a complex phenomenon that entails the interaction of multiple body systems to accomplish the basic task of remaining upright. There is a strong correlation between sitting balance and level of selfcare functioning” (Franc, 2020). For hearing, “…data suggest that people wait on average 7–10 yr after noticing hearing problems before seeking help (Davis et al, 2007). One potential reason for the delay in uptake of hearing health care is that the onset of age-related hearing loss is very gradual, and thus individuals may be unaware of the extent of their impairment. As a result, they do not perceive a need for help (Fischer et al, 2011; Smith et al, 2011; Contrera et al, 2016). As noted by Smith et al (2011), population screening can give individuals who are unaware of a health problem an earlier awareness of that problem” (Saunders, 2019). “Swallowing impairment, or dysphagia, is a known complication of cardiovascular surgical procedures that is reported in up to 70% of patients (Daly et al., 2016). Postoperative dysphagia is associated with delayed resumption of oral intake (Barker et al., 2009), increased likelihood of reintubation (Skoretz et al., 2014), pneumonia (Miles et al., 2018), prolonged hospital stay (Barker et al., 2009), increased cost of care (Kozlow et al., 2003) and mortality (Bicer et al., 2005; Ferraris et al., 2001)…Early and accurate detection of dysphagia is therefore critical to allow timely interventions that optimise patient care (O’Horo et al., 2015)” (York, 2020).