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Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
(04/01/2015 to 06/30/2015 Dates of Service)
Pilot Measure Specifications
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Description
The average change in functional status within 12 weeks of a treatment start
date for adult patients experiencing acute or sub-acute low back pain.
Methodology
Population identification is accomplished via a query of a practice management
system or Electronic Medical Record (EMR) to identify the population of eligible
patients (denominator). Data elements are either extracted from an EMR
system or abstracted through medical record review. Full population data is
required.
Rationale
In the United States, the lifetime prevalence for back pain is approximately
80%, with a 3 month prevalence rate of 28%. According to the CDC, the
National Health Interview Survey in 2012 showed the highest 3 month
prevalence is in adults ages 45-64 (32.3%). In 2005, the CDC study based on
census data reported that 7.6 million Americans had a disability related to back
pain, making back pain the second leading cause of disability in the country.
Back pain comes to a great expense to our country. Back pain is the sixth most
costly health condition in the United States. According to the CDC, in 2010, back
pain was in the top five acute principal reasons for a primary care office visit.
The healthcare costs associated with back pain account for more than $12
billion per year in the United States. Americans spend approximately $50 to
$100 billion on back pain each year. This total represents the more readily
available costs for medical care, workers compensation payments and time lost
from work.
Measurement Period
Pilot Testing measurement period for treatment start dates will be a fixed 3month period: 04/01/2015 to 06/30/2015 with allowance for subsequent follow
up to occur through 09/21/2015.
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Initial Patient
Population
Patients who meet each of the following criteria are included in the population:
• Patient aged 18 years or older at the start of the measurement period.
• Patient had an outpatient face to face encounter (Table 1) with an
eligible provider in an eligible specialty with a low back pain related
ICD-9 diagnosis code (Table 2) in the primary position.
Treatment Start Date: The earliest date of service for an outpatient face to face
encounter during the measurement period with a principal diagnosis of low
back pain.
Eligible specialties: Chiropractic Medicine
[Specialties not eligible for this period but with potential future applicability if
tested: Family Medicine, Geriatric Medicine, Internal Medicine, Occupational
Medicine, Orthopedic Medicine/Surgery, Neurosurgery, Physiatry, Physical
Therapy/Rehabilitation Medicine, Acupuncture and Oriental Medicine]
Eligible providers: Doctor of Chiropractic (DC)
[Providers not eligible for this period but with potential future applicability if
tested: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant
(PA), Advanced Practice Registered Nurses (APRN), Physical Therapist,
Acupuncturist (LAc)]
Exclusions
Exclusions from eligible population definition (allowed prior to submission):
•
Patients with any same-specialty encounter in the 180 days prior to the
treatment start date that included a low back pain related ICD-9
diagnosis code (Table 2) in any position.
•
Patients with a diagnosis of cancer, trauma or infection related to the
spine; drug abuse; or neurologic impairment (Table 3) any time during
the previous or current measurement year.
•
Patients who were pregnant (Table 4) during the measurement period.
Calculated exclusion (based on data submission):
•
Patients who report that current symptoms began more than 3 months
prior to the treatment start date.
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© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Measure Calculation
– Functional Status
Change within 12
weeks
Outcome measure
Measures the average change in functional status within the first 12 weeks of
treatment for patients experiencing acute or sub-acute low back pain
•
•
•
•
•
Step 1: For each eligible patient, obtain the ODI v2.1a result from the
treatment start date
Step 2: For each eligible patient, obtain the most recent ODI v2.1a
result occurring on or prior to 12 weeks after the treatment start date.
Step 3: For each eligible patient, calculate the change in functional
status
o ODIstart – ODI12weeks
Step 4: Sum the change in functional status for all eligible patients
Step 5: Divide by the number of eligible patients
Measure Calculation
– ODI Administration
at Treatment Start
Supporting process
measure
The percentage of eligible patients with an Oswestry Disability Index (ODI) v2.1a
result recorded in the medical record on the treatment start date.
Measure Calculation
– Follow Up ODI
Administration
within 12 weeks
Supporting process
measure
The percentage of eligible patients with an Oswestry Disability Index (ODI) v2.1a
result recorded in the medical record on or prior to 12 weeks after the
treatment start date.
Measure Calculation
– ODI Administration
at BOTH Treatment
Start AND within 12
weeks
Supporting process
measure
The percentage of eligible patients with an Oswestry Disability Index (ODI) v2.1a
result recorded in the medical record on BOTH the treatment start date AND on
or prior to 12 weeks after the treatment start date.
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Data elements of
clinical importance
for analysis and/or
potential risk
adjustment
Data elements determined to be useful for assessing risk and predicting future
outcomes will be collected as part of the data submission. Proposed elements
include:
Data elements submitted as part of MNCM standard demographic data
elements:
• Age
• Gender
• Health plan product
Data elements specific to this patient population:
• Functional status at Treatment Start Date
• Duration of low back pain at Treatment Start Date
• Active or pending motor vehicle accident, worker’s compensation
and/or personal injury claim
• Presence or absence of radicular pain
Table 1: CPT Codes for Identifying Eligible Face to Face Encounters
CPT Codes
Code Description
97001
Physical therapy evaluation
97810
Acupuncture, without electrical stimulation
97813
Acupuncture, with electrical stimulation
99201
Office or other outpatient visit, New patient, Level I
99202
Office or other outpatient visit, New patient, Level II
99203
Office or other outpatient visit, New patient, Level III
99204
Office or other outpatient visit, New patient, Level IV
99205
Office or other outpatient visit, New patient, Level V
99211
Office or other outpatient visit, Established patient, Level I
99212
Office or other outpatient visit, Established patient, Level II
99213
Office or other outpatient visit, Established patient, Level III
99214
Office or other outpatient visit, Established patient, Level IV
99215
Office or other outpatient visit, Established patient, Level V
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Table 2: ICD-9 Diagnosis Codes for Identifying Low Back Pain
ICD-9
ICD-9 Diagnosis Code Description
Diagnosis
Code
353.1
Lumbosacral plexus lesions
353.4
Lumbosacral root lesions, not elsewhere classified
355.0
Lesion of sciatic nerve
720.2
Sacroiliitis, not elsewhere classified
720.9
Unspecified inflammatory spondylopathy
721.3
Lumbosacral spondylosis without myelopathy
721.90
Spondylosis of unspecified site without mention of myelopathy
722.10
Displacement of lumbar intervertebral disc without myelopathy
722.52
Degeneration of lumbar or lumbosacral intervertebral disc
722.93
Other and unspecified disc disorder, lumbar region
724.02
Spinal stenosis, lumbar region, without neurogenic claudication
724.2
Lumbago
724.3
Sciatica
724.4
Thoracic or lumbosacral neuritis or radiculitis, unspecified
724.5
Backache, unspecified
724.6
Disorders of sacrum
724.70
Unspecified disorder of coccyx
724.71
Disorders of coccyx, hypermobility of coccyx
724.79
Disorders of coccyx, other
724.8
Other symptoms referable to back
724.9
Other unspecified back disorders
739.3
Nonallopathic lesions, lumbar region
739.4
Nonallopathic lesions, sacral region
739.5
Nonallopathic lesions, pelvic region
846.0
Sprains and strains of lumbosacral (joint) (ligament)
846.1
Sprains and strains of sacroiliac ligament
846.2
Sprains and strains of sacrospinatus (ligament)
846.3
Sprains and strains of sacrotuberous (ligament)
846.8
Sprains and strains of other specified sites of sacroiliac region
846.9
Sprains and strains of unspecified site of sacroiliac region
847.2
Sprains and strains of lumbar
847.3
Sprains and strains of sacrum
847.4
Sprains and strains of coccyx
848.5
Sprains and strains of pelvis
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© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Table 3: ICD-9 Diagnosis Codes for Identifying Patients Meeting Exclusion Criteria
ICD-9
ICD-9 Diagnosis Code Description
Diagnosis
Code
170.2
Malignant neoplasm bone & cartilage vertebral column
170.6
Malignant neoplasm bone & cartilage pelvic, sacrum, coccyx
192.2
Malignant neoplasm of other and unspecified parts of nervous system, spinal cord
198.5
Secondary malignant neoplasm ; bone and bone marrow
213.2
Benign neoplasm bone & cartilage vertebral column
213.6
Benign neoplasm bone & cartilage pelvic, sacrum, coccyx
238.0
Neoplasm uncertain behavior bone & cartilage
239.2
Neoplasm unspecified nature bone & cartilage
304.0x
Opioid type dependence
304.1x
Sedative, hypnotic or anxiolytic dependence
304.2x
Cocaine dependence
304.4x
Amphetamine and other psychostimulant dependence
305.4x
Sedative, hypnotic or anxiolytic abuse
305.5x
Opioid abuse
305.6x
Cocaine abuse
305.7x
Amphetamine or related acting sympathomimetic abuse
344.60
Caudaequina syndrome without mention of neurogenic bladder
344.61
Caudaequina syndrome with mention of neurogenic bladder
721.42
Lumbar spondylosis with myelopathy
729.2
Neuralgia, neuritis, and radiculitis, unspecified
730.x5
Osteomyelitis, periostitis, and other infections involving bone, pelvic region and thigh
730.x8
Osteomyelitis, periostitis, and other infections involving bone, other specified sites
730.x9
Osteomyelitis, periostitis, and other infections involving bone, multiple sites
805.4
Fracture, lumbar closed
805.5
Fracture, lumbar open
805.6
Fracture, sacrum & coccyx closed
805.7
Fracture, sacrum & coccyx open
806.4
Fracture w/spinal cord injury, lumbar closed
806.5
Fracture w/spinal cord injury, lumbar open
806.60
Fracture w/spinal cord injury, sacrum, coccyx closed unspecified
806.61
Fracture w/spinal cord inj, sac/cocc closed caudaequina lesion
806.62
Fracture w/spinal cord inj, sac/cocc closed caudaequina other
806.69
Fracture w/spinal cord inj, sac/cocc closed other spinal cord inj
806.70
Fracture w/spinal cord injury, sacrum, coccyx open unspecified
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ICD-9
Diagnosis
Code
806.71
806.72
806.79
733.13
733.82
905.1
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
ICD-9 Diagnosis Code Description
Fracture w/spinal cord inj, sac/coccyx open caudaequina lesion
Fracture w/spinal cord inj, sac/coccyx open caudaequina other
Fracture w/spinal cord inj, sac/coccyx open other spinal cord inj
Pathologic fracture of vertebrae
Non-union of fracture (pseudoarthrosis)
Late effect fracture of the spine and trunk without mention of spinal cord lesion
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© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Table 4: It is acceptable to use both set of codes to identify pregnancy, depending on coding practices in
the medical group. If ICD-9 V-Codes are used consistently, it is acceptable to use these codes for
populating an exception for pregnancy. If ICD-9 V-Codes are not used, or not used consistently, it is
recommended to use the ICD-9 diagnosis code ranges that indicate pregnancy.
Table 4a: ICD-9 V-Codes that Indicate Pregnancy
ICD-9 V-Code ICD-9 V-Code Description
V22.0
Supervision of normal first pregnancy
V22.1
Supervision of other normal pregnancy
V22.2
Pregnant state, incidental
V23.0
Pregnancy with history of infertility
V23.1
Pregnancy with history of trophoblastic disease
V23.2
Pregnancy with history of abortion
V23.3
Grand multiparity
V23.41
Pregnancy with history of pre-term labor
V23.42
Pregnancy with history of ectopic pregnancy
V23.49
Pregnancy with other poor obstetrical history
V23.5
Pregnancy with other poor reproductive history
V23.7
Insufficient prenatal care
V23.81
Elderly primigravida
V23.82
Elderly multigravida
V23.83
Young primigravida
V23.84
Young multigravida
V23.85
Pregnancy resulting from assisted reproductive technology
V23.86
Pregnancy with history of in utero procedure during previous pregnancy
V23.87
Pregnancy with inconclusive fetal viability
V23.89
Other high risk pregnancy
Table 4b: ICD-9 Diagnosis Codes that Indicate Pregnancy
ICD-9 Code Start
End of Range
Description of Range
630
to 639.x
Ectopic and Molar Pregnancy and Other Pregnancy with
Abortive Outcome
640.xx
to 649.xx
Complications Mainly Related to Pregnancy
650
to 659.xx
Normal Delivery and Other Indications for Care in Pregnancy,
Labor and Delivery
660.xx
to 669.xx
Complications Occurring Mainly in the Course of Labor and
Delivery
670.xx
to 677
Complications Of the Puerperium
678.xx
to 679.xx
Other Maternal and Fetal Complications
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© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Acute and Sub-Acute Low Back Pain
Measure Flow Chart
Was the patient born on or prior
to 04/01/1997
PATIENT NOT
INCLUDED IN
DATA
SUBMISSION
No
Yes
No
Did the patient have an
outpatient face to face
encounter (Table 1) with an
eligible provider during the
measurement period
(4/1/2015 – 6/30/2015)?
(Treatment Start)
Yes
Yes
Yes
No
Was an ICD-9 diagnosis code
(Table 2) for low back pain in
the primary position for the
encounter?
Did the patient have any samespecialty encounters for low
back pain in the 180 days
prior?
Yes
No
Yes
Did the patient have an
exclusion diagnosis (Table 3)
any time between 4/1/2014 –
9/21/2015?
No
Was the patient pregnant
(Table 4) any time between
4/1/2015 – 9/21/2015?
No
Change in ODI
calculated. Result
included in outcome
measure.
Yes
Did the patient
complete a follow
up ODI v2.1a
within 12 weeks of
Treatment Start?
Yes
Did the patient
complete an ODI
v2.1a at Treatment
Start?
No
Patient
included in
process measure
denominators
No
Does the patient
report that current
symptoms began
more than 3
months prior to
Treatment Start?
PATIENT
INCLUDED IN
DATA
SUBMISSION
No
Yes
Patient NOT included
in outcome measure
Patient NOT
included in
Measure Set
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© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Data Elements and Field Specifications
Use this section to build your data submission. The specifications contain detailed information regarding each column in the submission file that you will
need to complete, including column order, definitions, examples, and appropriate formatting.
Column Field Name
Notes
Excel Format
Example
A
Clinic ID
Enter the MNCM Clinic ID for every patient/row submitted. MNCM assigns the clinic
ID at the time of registration. Use the MNCM ID listed in the MNCM Data Portal. Do
NOT use the Medical Group ID.
Blank values will create ERRORs upon submission.
Text
905
B
Patient ID
Enter a unique patient ID to identify each patient.
Text
56609
•
Keep a “crosswalk” between patient IDs and the patient names/DOBs to help clinic
staff locate records during validation audits.
• Enter clinic-assigned ID (e.g., MRN, account number). Do NOT enter Social Security
Numbers.
Blank values will create ERRORs upon submission.
C
Patient Date of
Birth
Enter patient’s date of birth. Patient must be 18 years or older at the start of the
measurement period.
Blank values or values prior to 04/01/1997 will create ERRORs upon submission.
Quality Check: Verify each date of birth is within the accepted range.
Date
(mm/dd/yyyy)
05/08/1985
D
Patient Gender
Enter patient’s gender.
Female = F
Male = M
Unknown = U
Blank values will create ERRORs upon submission.
Quality Check: Verify each cell has one of the accepted codes.
Text
F
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Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Column Field Name
Notes
E
Enter the five-digit zip code of patient’s primary residence at the most recent
encounter on or prior to 9/21/2015.
Patient Zip
Code
Excel Format
Example
Text
55111
•
If EMR query extracts a nine-digit number, submit the nine-digit number. The
MNCM Data Portal will remove the last four digits automatically.
Blank values will create ERRORs upon submission.
Quality Check: Verify the zip code is at least five digits and each cell has data.
F
G
H
I
J
K
L
M
N
Race/Ethnicity
1
Race/Ethnicity
2
Race/Ethnicity
3
Race/Ethnicity
4
Race/Ethnicity
5
Country of
Origin Code
Country of
Origin “Other”
Description
Preferred
Language Code
Preferred
Language
“Other”
Description
Please refer to the separate document, REL Data Field Specifications & Codes, for the
field specifications in Columns F-N.
These are optional fields.
For more information about collecting this data from patients, refer to the Handbook
on the Collection of REL Data in Medical Groups.
Quality Check: Verify each cell has one of the accepted codes. Blank cells (if there is
no data available) are acceptable.
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© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Column Field Name
Notes
O
Provider NPI
Number
Enter the 10 digit NPI number of the eligible provider.
Blank values will create ERRORs upon submission.
Quality Check: Verify each cell has data.
Text
P
Provider
Specialty Code
Enter the code for the specialty of the eligible provider.
TBD = Chiropractic Medicine
Number
22
Number
1
Text
Assurant
Health
Quality Check: Verify each cell has an accepted code and that all 99 codes have a
name entered in Column R. Verify Social Security Numbers are NOT submitted.
Text
FBOXZ7969
Enter the earliest date of service for an outpatient face to face encounter during the
measurement period with a principal diagnosis of low back pain.
Blank values or values outside the measurement period will create ERRORs upon
submission.
Quality Check: Verify all dates are between 04/01/2015 to 06/30/2015.
Date
(mm/dd/yyyy)
5/10/2015
Q
R
S
T
Insurance
Coverage Code
Insurance
Coverage
“Other”
Description
Insurance Plan
Member ID
Treatment
Start Date
Blank values will create ERRORs upon submission.
Quality check: Verify each cell has an accepted code.
Please refer to a separate document, 2015 Insurance Coverage Data Field
Specifications and Codes, for these field specifications.
Excel Format
This should be the patient’s most recent insurance on or prior to 9/21/2015.
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Example
1997993992
Column Field Name
U
Duration of low
back pain at
Treatment
Start Date
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Notes
Enter the value corresponding to the patient’s response at treatment start to the
following question:
When did your current symptoms begin?
0 = Less than 2 weeks ago
1 = 2 – 6 weeks ago
2 = 6 weeks – 3 months ago
3 = More than 3 months ago
Leave BLANK if the patient does not answer or if there is no documentation
For patients with a “3” in Field U:
V
Claim Type
Excel Format
Example
STOP. For patients with a duration of low back pain at Treatment Start Date of More than 3 months ago, the
remaining fields (V – AR) are not required.
Enter the value that indicates whether the patient has an active or pending motor
vehicle accident, worker’s compensation or other personal injury claim related to
this episode of treatment.
0 = No, the patient does not have an active or pending claim of these types
1 = Yes, the patient has an active or pending claim of these types
Number;
Whole
numbers only
1
Number;
Whole
numbers only
0
Blank values will create ERRORs upon submission.
W
Radicular Pain
Enter the value that indicates whether the patient has radicular pain associated with
this episode of low back pain.
0 = No, the patient does not have radicular pain
1 = Yes, the patient does have radicular pain
Blank values will create ERRORs upon submission.
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Column Field Name
Notes
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
For all Oswestry Disability Index (ODI) Fields; refer to Appendix A for more information about how to implement and score the ODI v2.1a.
X
Treatment
Start –
ODI Pain
Enter the value that corresponds with the patient’s selection for ODI Section 1- Pain
intensity.
0 = I have no pain at the moment.
1 = The pain is very mild at the moment.
2 = The pain is moderate at the moment.
3 = The pain is fairly severe at the moment.
4 = The pain is very severe at the moment.
5 = The pain is the worst imaginable at the moment.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
2
Y
Treatment
Start –
ODI Care
Enter the value that corresponds with the patient’s selection for ODI Section 2Personal Care (washing, dressing, etc.).
0 = I can look after myself normally without causing additional pain.
1 = I can look after myself normally but it is very painful.
2 = It is painful to look after myself and I am slow and careful.
3 = I need some help but manage most of my personal care.
4 = I need help every day in most aspects of my personal care.
5 = I do not get dressed, I wash with difficulty and stay in bed.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
1
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Column Field Name
Notes
Z
Treatment
Start –
ODI Lifting
AA
Treatment
Start –
ODI Walking
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 3- Lifting.
0 = I can lift heavy weights without additional pain.
1 = I can lift heavy weights but it give me additional pain.
2 = Pain prevents me from lifting heavy weights off the floor but I can manage if
they are conveniently positioned, e.g. on a table.
3 = Pain prevents me from lifting heavy weights, but I can manage light to medium
weights if off they are conveniently positioned.
4 = I can lift only very light weights.
5 = I cannot lift ot carry anything at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
4
Enter the value that corresponds with the patient’s selection for ODI Section 4Walking.
0 = Pain does not prevent me from walking any distance.
1 = Pain prevents me from walking more than one mile.
2 = Pain prevents me from walking more than a quarter of a mile.
3 = Pain prevents me from walking more than 100 yards.
4 = I can only walk using a cane or crutches.
5 = I am in bed most of the time and have to crawl to the toilet.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
2
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Column Field Name
Notes
AB
Treatment
Start –
ODI Sitting
AC
Treatment
Start –
ODI Standing
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 5- Sitting.
0 = I can sit in any chair as long as I like.
1 = I can sit in my favorite chair as long as I like.
2 = Pain prevents me from sitting more than one hour.
3 = Pain prevents me from sitting more than half an hour.
4 = Pain prevents me from sitting more than 10 minutes.
5 = Pain prevents me from sitting at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
1
Enter the value that corresponds with the patient’s selection for ODI Section 6Standing.
0 = I can stand as long as I want without additional pain.
1 = I can stand as long as I want but it gives me additional pain.
2 = Pain prevents me from standing more than one hour.
3 = Pain prevents me from standing more than half an hour.
4 = Pain prevents me from standing more than 10 minutes.
5 = Pain prevents me from standing at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
3
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Column Field Name
Notes
AD
Treatment
Start –
ODI Sleeping
AE
Treatment
Start –
ODI Sex, if
applicable
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 7Sleeping.
0 = My sleep is never interrupted by pain.
1 = My sleep is occassionally interrupted by pain.
2 = Because of pain I have less than 6 hours of sleep.
3 = Because of pain I have less than 4 hours of sleep.
4 = Because of pain I have less than 2 hours of sleep.
5 = Pain prevents me from sleeping at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
1
Enter the value that corresponds with the patient’s selection for ODI Section 8- Sex
life.
0 = My sex life is normal and causes no additional pain.
1 = My sex life is normal but causes some additional pain.
2 = My sex life is nearly normal but is very painful.
3 = My sex life is severly restricted by pain.
4 = My sex life is nearly nonexistant because of pain.
5 = Pain prevents me from having any sex life at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
2
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Column Field Name
Notes
AF
Treatment
Start –
ODI Social
AG
Treatment
Start –
ODI Travelling
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 9- Social
Life.
0 = My social life is normal and causes no additional pain.
1 = My social life is normal but increases the degree of pain.
2 = Pain has no significant effect on my social life apart from limiting my more
energetic interests.
3 = Pain has restricted my social life and I do not go out as often.
4 = Pain has restricted my social life to home.
5 = I have no social life becasue of pain.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
0
Enter the value that corresponds with the patient’s selection for ODI Section 10Travelling.
0 = I can travel anywhere without pain.
1 = I can travel anywhere but it gives me additional pain.
2 = Pain is bad but I’m able to manage trips over two hours.
3 = Pain restricts me to trips on less than one hour.
4 = Pain restricts me to short necessary trips of under 30 minutes.
5 = Pain prevents me from travelling except to receive treatment.
If a patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
0
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Column Field Name
Notes
AH
12WeekODI
Date
AI
AJ
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the most recent date corresponding to an ODI v2.1a administration on or prior
to 12 weeks after the treatment start date.
Leave BLANK if a follow up ODI v2.1a was not administered on or prior to 12 weeks
after the treatment start date.
Date
(mm/dd/yyyy)
11/12/2013
12 Weeks - ODI
Pain
Enter the value of the patient’s selection for ODI Section 1- Pain intensity.
0 = I have no pain at the moment.
1 = The pain is very mild at the moment.
2 = The pain is moderate at the moment.
3 = The pain is fairly severe at the moment.
4 = The pain is very severe at the moment.
5 = The pain is the worst imaginable at the moment.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
2
12 Weeks - ODI
Care
Enter the value of the patient’s selection for ODI Section 2- Personal Care (washing,
dressing, etc.).
0 = I can look after myself normally without causing additional pain.
1 = I can look after myself normally but it is very painful.
2 = It is painful to look after myself and I am slow and careful.
3 = I need some help but manage most of my personal care.
4 = I need help every day in most aspects of my personal care.
5 = I do not get dressed, I wash with difficulty and stay in bed.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
1
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Column Field Name
Notes
AK
12 Weeks - ODI
Lifting
AL
12 Weeks - ODI
Walking
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 3- Lifting.
0 = I can lift heavy weights without additional pain.
1 = I can lift heavy weights but it give me additional pain.
2 = Pain prevents me from lifting heavy weights off the floor but I can manage if
they are conveniently positioned, e.g. on a table.
3 = Pain prevents me from lifting heavy weights, but I can manage light to medium
weights if off they are conveniently positioned.
4 = I can lift only very light weights.
5 = I cannot lift ot carry anything at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
4
Enter the value that corresponds with the patient’s selection for ODI Section 4Walking.
0 = Pain does not prevent me from walking any distance.
1 = Pain prevents me from walking more than one mile.
2 = Pain prevents me from walking more than a quarter of a mile.
3 = Pain prevents me from walking more than 100 yards.
4 = I can only walk using a cane or crutches.
5 = I am in bed most of the time and have to crawl to the toilet.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
2
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Column Field Name
Notes
AM
12 Weeks - ODI
Sitting
AN
12 Weeks - ODI
Standing
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 5- Sitting.
0 = I can sit in any chair as long as I like.
1 = I can sit in my favorite chair as long as I like.
2 = Pain prevents me from sitting more than one hour.
3 = Pain prevents me from sitting more than half an hour.
4 = Pain prevents me from sitting more than 10 minutes.
5 = Pain prevents me from sitting at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
1
Enter the value that corresponds with the patient’s selection for ODI Section 6Standing.
0 = I can stand as long as I want without additional pain.
1 = I can stand as long as I want but it gives me additional pain.
2 = Pain prevents me from standing more than one hour.
3 = Pain prevents me from standing more than half an hour.
4 = Pain prevents me from standing more than 10 minutes.
5 = Pain prevents me from standing at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
3
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Column Field Name
Notes
AO
12 Weeks - ODI
Sleeping
AP
12 Weeks - ODI
Sex, if
applicable
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 7Sleeping.
0 = My sleep is never interrupted by pain.
1 = My sleep is occassionally interrupted by pain.
2 = Because of pain I have less than 6 hours of sleep.
3 = Because of pain I have less than 4 hours of sleep.
4 = Because of pain I have less than 2 hours of sleep.
5 = Pain prevents me from sleeping at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
1
Enter the value that corresponds with the patient’s selection for ODI Section 8- Sex
life.
0 = My sex life is normal and causes no additional pain.
1 = My sex life is normal but causes some additional pain.
2 = My sex life is nearly normal but is very painful.
3 = My sex life is severly restricted by pain.
4 = My sex life is nearly nonexistant because of pain.
5 = Pain prevents me from having any sex life at all.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
2
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Column Field Name
Notes
AQ
12 Weeks - ODI
Social
AR
12 Weeks - ODI
Travelling
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Excel Format
Example
Enter the value that corresponds with the patient’s selection for ODI Section 9- Social
Life.
0 = My social life is normal and causes no additional pain.
1 = My social life is normal but increases the degree of pain.
2 = Pain has no significant effect on my social life apart from limiting my more
energetic interests.
3 = Pain has restricted my social life and I do not go out as often.
4 = Pain has restricted my social life to home.
5 = I have no social life becasue of pain.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
0
Enter the value that corresponds with the patient’s selection for ODI Section 10Travelling.
0 = I can travel anywhere without pain.
1 = I can travel anywhere but it gives me additional pain.
2 = Pain is bad but I’m able to manage trips over two hours.
3 = Pain restricts me to trips on less than one hour.
4 = Pain restricts me to short necessary trips of under 30 minutes.
5 = Pain prevents me from travelling except to receive treatment.
If patient selects more than one response to a question, submit the highest (worst)
response.
Leave BLANK if the patient does not answer or if there is no documentation.
Number;
Whole
numbers only
0
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Appendix A: Functional Status (Oswestry Disability Index, v2.1a)
Ideally tools are completed by the patient at the time of treatment; however office visits are not
required for tool completion. Any provider or office staff may administer the initial and follow-up
instruments.
Modes of acceptable administration
Administration Mode
In person/during visit
Acceptable
Via mail
Acceptable
Via telephone
Not Acceptable*
Administer electronically **
Acceptable
*Instrument has not been validated for telephone administration.
**When administering electronically, the tools must be kept intact including content, order and scoring.
Electronic examples: Email, patient portal, iPad/tablet, patient kiosk.
Other Activities
Store results in EMR
Must seek approval for other
uses (examples: Research,
publication, use of tool beyond
measure population, etc.)
Acceptable
Yes
Regardless of the successful administration of the ODI, all patients who meet the initial patient
population criteria after upfront exclusions must be included in the data submission file. For example:
•
A patient who has no initial or follow up functional status score must still be included in the data
submission file.
• A patient who has either an initial or a follow up functional status score must still be included in
the data submission file.
• A patient who has initial and follow up functional status scores must be included in the data
submission file.
The MNCM Data Portal will calculate process measures based on the submission to determine the rate
of administration of the instruments at treatment start date and in follow up.
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.
Acute and Sub-Acute Low Back Pain
Functional Status Outcome Measure 2015
Direct Data Submission
Measurement Specifications
Oswestry Disability Index (ODI) version 2.1a
This is a patient completed survey consisting of 10 structured questions asking the patient to describe
the impact of their low back pain and function in the following areas: pain, personal care, lifting,
walking, sitting, standing, sleeping, sex life (if applicable), social life, and ability to travel. More
information can be found at
http://www.proqolid.org/instruments/oswestry_disability_index_odi?fromSearch=yes&text=yes.
The MNCM Data Portal will evaluate all incoming responses, if eight of the ten questions are completed
by the patient, the assessment tool can be used and the MNCM Data Portal will calculate a score. The
MNCM Data Portal will score appropriately, recalculating the denominator as recommended by the
developer, Jeremy Fairbank.
If an ODI was administered and any answers were skipped, leave the correlated fields blank in the data
file. Do not replace a blank response with a zero as this is a valid response in the instrument.
If a patient selects more than one response to a question, submit the highest (worst) response.
References
ODI © Jeremy Fairbank, 1980. All Rights Reserved. ODI - United States/English - Version of 29 Jul 11 Mapi Institute. ID6287/ODI_AU2.1a_eng-US.doc
Fairbank J, Pynsent PB. The Oswestry Disability Index. Spine 2000; 25(22):2940-2953
Baker DJ, Pynsent PB and Fairbank JCT (1989) The Oswestry Disability revisited. In Roland Jenner JR (eds)
Back pain: New approaches to rehabilitation and education. Manchester University Press.pp174-186
Fairbank JCT, Couper J, Davies JB, O’Brien JP. The Oswestry Low Back Pain Disability
Questionnaire.Physiotherapy. 1980; 66:271-273
Permissions
MNCM obtained permission to make the ODI version 2.1a available on the MNCM Data Portal for use by
providers participating in MNCM reporting and improvement efforts. This tool is also available in the
public domain and is free of charge for use in clinical practice.
For research use, please refer to the MAPI Trust website for more information:
http://www.proqolid.org/instruments/oswestry_disability_index_odi?fromSearch=yes&text=yes
The tool developer, Dr. Jeremy Fairbank, has stipulated as a part of the user agreement that for all new
studies, version 2.1a of the ODI must be used.
Helpline: 612-746-4522 | E-mail: [email protected] | MNCM Data Portal: https://data.mncm.org/login
© MN Community Measurement, 2015. All rights reserved.