Metric 11

Use of Physical Therapy Before Initial Lumbar Surgery for Low Back Pain

Metric Category: Appropriateness

About the Metric

Definition

The percentage of patients who underwent at least one physical therapy session within 12 months prior to lumbar spine surgery. 

Background

Randomized trials have suggested that surgical decompression procedures can yield similar clinical results to a physical therapy regimen among patients with low back pain.

Metric Ratings

Evidence
5/5
Expert Consensus
4.5/5
Clinician Buy-in
3.5/5
Economic Impact
5/5
Reduction in Avoidable Harm
5/5
Applicability to Medicare Data
5/5
Applicability to Medicaid
4/5

Applicable to EHR Data?

Requires Pharmacy Data?

How It Works

Numerator

The number of patients from the denominator who underwent at least one physical therapy session (CPT codes:97032, 97035, 97110, 97112, 97113, 97116, 97124, 97140, 97161, 97162, 97163, 97164, 97530, 97535) within 12 months before their lumbar surgery (CPT codes: 20930, 20936, 22102, 22103, 22224, 22226, 22558, 22585, 22612, 22630, 22802, 22840, 22842, 22843, 22844, 22853, 22854, 22859, 62287, 63005, 63011, 63012, 63030, 63035, 63042, 63047, 63048, 63088, 63090, 63091, 63185, 63190, 63200, 63267, 63272, 63290, 63303, 64633, 64634, and 64636).

Denominator

The number of patients who underwent an elective lumbar surgery (CPT codes: 20930, 20936, 22102, 22103, 22224, 22226, 22558, 22585, 22612, 22630, 22802, 22840, 22842, 22843, 22844, 22853, 22854, 22859, 62287, 63005, 63011, 63012, 63030, 63035, 63042, 63047, 63048, 63088, 63090, 63091, 63185, 63190, 63200, 63267, 63272, 63290, 63303, 64633, 64634, and 64636) for spinal stenosis, spondylolysis, spondylolisthesis, lumbar radiculopathy or other non-traumatic back pain symptoms (ICD-10-CM codes: M48.05, M48.06, M48.07, M43.05, M43.06, M43.07, M43.09, M43.15, M43.16, M43.17, M43.19, M54.15, M54.16, M54.17, M54.5, M54.30, M54.31, M54.32, M54.40, M54.41, M54.42, S33.5, S33.8).

Inclusion Criteria

All patients who underwent an elective lumbar surgery for spinal stenosis, spondylolysis, spondylolisthesis, lumbar radiculopathy or other non-traumatic back pain symptoms.

Exclusion Criteria

1. Patients whose lumbar surgery was performed for traumatic or compression spinal fracture, nervous. system disorder, spinal cord injury, spinal infection ( ICD-10-CM codes: G83.4; M46.25; M46.26; M46.27; M46.35, M46.36, M46.37, M46.39; S32.0, S32.9, S34.01, S34.10, S34.11, S34.12, S34.21, S34.4, S34.5)

 

2. Patients with a diagnosis of any type of cancer (ICD-10-CM codes: C00 – C96, C7A, C7B) before or on the day of the lumbar surgery.

 

3. Patients with any history of lumbar surgery (CPT codes: 20930, 20936, 22102, 22103, 22224, 22226, 22558, 22585, 22612, 22630, 22802, 22840, 22842, 22843, 22844, 22853, 22854, 22859, 62287, 63005, 63011, 63012, 63030, 63035, 63042, 63047, 63048, 63088, 63090, 63091, 63185, 63190, 63200, 63267, 63272, 63290, 63303, 64633, 64634, and 64636) prior to the study period.

Attribution

None.

GAM Thresholds™

GAM establishes clinical thresholds using the input of key physician leaders within a specialty and the GAM clinical team. GAM utilizes an elaborate consensus building process with final adjudication by our leadership team.

  • Sample Size: 11+

    This threshold applies to a clinician with a minimum of 11 cases.

  • Pattern of Concern: <20%

    This constitutes the clinical threshold for a "pattern of concern".

  • Outlier: 0%

    This constitutes the clinical threshold for an "outlier" (i.e. 0% of patients got physical therapy before lumbar surgery).

Cases Pattern of Concern Outlier
11+
<20%
0%