Distal Symmetric Polyneuropathy

Distal Symmetric Polyneuropathy
Performance Measurement Set
Status: American Academy of Neurology Board of Directors Approved 07.30.2012

and
American Association of Neuromuscular and Electrodiagnostic Medicine Board of Directors approved
10.11.13
©2012. American Academy of Neurology. All Rights Reserved.

CPT Copyright 2009 American Medical Association.
Physician Performance Measures (Measures) and related data specifications developed by the American Academy of Neurology
(AAN) are intended to facilitate quality improvement activities by physicians.
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©2012. American Academy of Neurology. All Rights Reserved. 2

Table of Contents
Work Group Members Pg 4
Executive Summary Pg 5
Desired Outcomes for Patients with DSP Pg 9
Purpose of Measurement Set Pg 10
Importance of Topic Pg 10
Demonstrated Opportunity for Improvement Pg 11
Disparities Pg 11
Clinical Evidence Base Pg 11
Distal Symmetric Polyneuropathy Outcomes Pg 12
Intended Care Audience, Care Setting, and Patient Population Pg 12
Distal Symmetric Polyneuropathy Recommendations Pg 12
IOM Domains of Health Care Quality Pg 13
Other Potential Measures Pg 13
Measure Harmonization Pg 13
Potential for Future Measure Development in National Priority Partnership Areas Pg 13
Measure Implementation Initiative and Collaborative Pg 14
Technical Specifications Overview Pg 14
Measure Exceptions Pg 14
Testing and Implementation of the Measurement Set Pg 15
Measure #1: Distal Symmetric Polyneuropathy (DSP) Diagnosis Criteria: DSP Symptoms Pg 16
and Signs
Measure #2: Distal Symmetric Polyneuropathy (DSP) Diagnosis Criteria- Pg 19
Electrodiagnostic Studies
Measure #3: Diabetes/Pre-Diabetes Screening for Patients with DSP Pg 23
Measure #4: Screening for Unhealthy Alcohol Use Pg 26
Measure #5: Querying about Pain and Pain Interference with Function Pg 29
Measure #6: Querying about Falls for Patients with DSP Pg 32
Evidence Classification/Rating Schemes Pg 35
References Pg 37
Contact Information Pg 38

Work Group Members
Co-Chairs
John D. England, MD, FAAN
Gary M. Franklin, MD, MPH, FAAN
Quality Measurement and Reporting Subcommittee Facilitator

Richard M. Dubinsky, MD, MS
American Academy of Neurology American Academy of Physical

Gil Wolfe, MD Medicine and Rehabilitation
William David, MD Stephen Kishner, MD
Jeffrey Cohen, MD
Jonathan Goldstein, MD American Academy of Neuromuscular
Victoria Lawson, MD & Electrodiagnostic Medicine
Amanda Peltier, MD Pushpa Narayanaswami, MBBS, DM
Benn Smith, MD Catherine French, MAPL
Mazen Dimachkie, MD
Humana
American Diabetes Association Charles Stemple, DO
Susan Kirkman, MD
UnitedHealthcare
The Neuropathy Association Edwin Dasso, MD
Thomas Brannagan, MD
Natacha T. Pires, M.B.B.S. American Academy of Neurology Staff
Gina Gjorvad
Rebecca J. Swain-Eng, MS
Sarah Tonn, MPH
Methodologist
Rebecca Kresowik

Executive Summary: Toward Improving Outcomes for Patients with Distal Symmetric Polyneuropathy
The American Academy of Neurology (AAN) formed a Neuropathy Work Group to identify and define quality
measures towards improving outcomes for patients with neuropathy. The majority of the available evidence that
would meet a gap in care focused on distal symmetric polyneuropathy (DSP), therefore this measurement set is
focused on measures for patients with a diagnosis of DSP.
Reasons for Prioritizing Improvement in Distal Symmetric Polyneuropathy

High Impact Topic Area
• DSP represents a significant health problem because it is a chronic, high-cost disease and is often linked to
severe neuropathic pain and significant morbidity, increased mortality and impaired quality of life.1
• The onset of DSP is insidious and without appropriate intervention the course of the disease is progressive
and debilitating.2
• Peripheral neuropathy is estimated to affect more than 20 million Americans.3
• DSP is the most common variety of neuropathy and type of diabetic neuropathy.1,4 Approximately 30% of
neuropathies are caused by diabetes and 30% are idiopathic (or unknown cause).3 Other common causes of
neuropathy include autoimmune disorders, tumors, hereditary conditions, nutritional imbalances, infections
or toxins.3
• The most important etiological factors that have been associated with DSP are poor glycemic control,
diabetes duration, visceral obesity and height, with possible roles for hypertension, age, smoking,
hypoinsulinemia, and dyslipidemia.5,6
• Neuropathies affect up to 50% of patients with diabetes.7 DSP affects at least one in four diabetic patients.1
Diabetes is one of the five major chronic conditions that affect 25% of the US community population8 and
amounted to more than $62.3 billion health care costs in 1996.9
• The distal symmetric sensory or distal sensorimotor polyneuropathy represents the most relevant clinical
manifestation, affecting 30% of the hospital-based population and 25% of community-based samples of
diabetic patients.6
• The incidence of DSP is 2% per year.6
• A 1999 survey found that 8-9% of Medicare recipients have peripheral neuropathy as their primary or
secondary diagnosis.3 The annual cost to Medicare exceeds $3.5 billion.3
• Neuropathies also cause great morbidity because the symptoms severely decrease patients' quality of life.
Pain associated with diabetic neuropathy exerts a substantial impact on sleep and enjoyment of life.10,11
Patients describe pain-related interference in multiple health related quality of life (HR-QOL) and functional
domains, as well as reduced ability to work and reduced mobility due to their pain. The substantial costs to
society of DSP derive from direct medical costs, loss of the ability to work, loss of caregivers' ability to work
and possibly greater need for institutionalization or other living assistance.10 The secondary complications of
neuropathy such as falls, foot ulcers (estimated that foot ulcers occurs in approximately 2.5% of patients
with diabetes7),cardiac arrhythmias, and ileus are significant and can lead to fractures, amputations, and even
death in patients with diabetes.7 Despite this significant impact, 25% and 39% of the diabetic patients,
respectively, had no treatment for their pain in two surveys.12,13
• Therapy is aimed at treating the underlying disease or cause. Proper management of medications can also
improve the symptoms. An experienced neurologist can help patients feel more comfortable, improve the
patient’s quality of life, and help prevent further permanent damage.14

Demonstrated Opportunity for Improvement
• DSP is often difficult to diagnose reliably. It is often misdiagnosed or erroneously associated as the side
effect of another disease like kidney failure.3 Undiagnosed and untreated neuropathy may lead to disability
and poor quality of life. Neuropathy needs to be diagnosed early to prevent complications, such as
neuropathic pain or the diabetic foot.
• Since DSP is the major contributory factor for diabetic foot ulcers and the lower-limb amputation rates in
diabetic subjects are 15 times higher than in the non-diabetic population, an early detection of DSP by
screening and appropriate diagnosis are of utmost importance15. This is even more imperative because many
patients with DSP are asymptomatic or have only mild symptoms.
• Neuropathic pain is often more difficult to treat than many other types of chronic pain. Patients with
neuropathic pain have great medical co-morbidity burden than age- and sex-adjusted controls.10 Data
collected between 1988 and 1995 (derived from the Center for Disease Control's population-based
Behavioral Risk Factor Surveillance System [BRFSS], as well as the National Health and Nutrition
Examination [NHANES] surveys) reveal significant quality gaps in the treatment of diabetes and in
screening for diabetes-related complications.7 Diabetics also do not receive appropriate screening measures:
only 55% obtain annual foot examinations.16
Disparities
• There is currently no consistent data that shows disparities between minorities and whites for diabetes-
related neuropathy and peripheral vascular disease.17 DSP is more common in older adults. Older people are
among the top spenders on healthcare. They make up 13% of the US population in 2002, yet they
consumed 63% of health care expenses.6 Improving the effectiveness of diagnosis and optimizing patient
outcomes will become increasingly important as the population of the United States ages.
Rigorous Clinical Evidence Base

Evidence-based clinical practice guidelines and consensus papers are available for the management of distal
symmetric polyneuropathy. This measurement set is based upon guidelines or consensus papers from:
• American Academy of Neurology
• American Diabetes Association
• United States Preventive Services Task Force
• National Quality Forum Consensus Standards
• International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group with
additional support provided by the Neuropathic Pain Institute
• American Geriatrics Society
Distal Symmetric Polyneuropathy Outcomes

The work group attempted to develop measures of outcomes along with measures of processes that may improve
patient outcomes for DSP patients. Due to the lack of standardized diagnostics for DSP and measures already
developed by outside organizations for outcomes of untreated DSP (eg foot ulcerations), the work group felt there
were no specific outcomes that could be focused on. The Work Group decided to focus on performance measures
based upon processes that may achieve desired outcomes and reflect high quality care.
Desired outcomes for DSP include:

1. Establish and define appropriate DSP diagnostic criteria to ensure appropriate disease diagnosis
2. Promote appropriate testing and studies for DSP and related complications
3. Screen for underlying causes of DSP (diabetes, unhealthy alcohol use, etc.) to promote appropriate
treatment of DSP patients.
4. Assist patients in managing their pain and improving their quality of life
5. Promote patient safety and reduce falls
6. Reduce DSP complications (eg foot ulcers)
Distal Symmetric Polyneuropathy Work Group Recommendations

Process measures: Several processes of care demonstrated to improvement outcomes for patients with distal
symmetric polyneuropathy are recommended:
Distal Symmetric Polyneuropathy Measures
Measures addressing appropriate diagnosis

Measure #1: Distal Symmetric Polyneuropathy (DSP) Diagnosis Criteria: DSP Symptoms and Signs
Measure #2: Distal Symmetric Polyneuropathy (DSP) Diagnosis Criteria: Electrodiagnostic Studies
Measures addressing underuse of effective services (evaluation and treatment services)
Measure #3: Diabetes/Pre-Diabetes Screening for Patients with DSP
Measure #4: Screening for Unhealthy Alcohol Use
Measure addressing quality of life/morbidity
Measure #5: Querying about Pain and Pain Interference with Function
Measures addressing safety
Measure #6: Querying about Falls for Patients with DSP
These measures are designed for individual practitioner level quality improvement. Unless otherwise indicated the
measures are appropriate for accountability if the appropriate methodological, statistical, and implementation rules
are followed.
Other Potential Measures

The Work Group considered several other potential measures, though ultimately decided they were not appropriate
for inclusion in the measurement set.
Measure Harmonization
When existing measures are available for the same measurement topic, the AAN attempts to harmonize the
measures to the extent it is feasible. The AAN works to ensure there is no duplication of existing measures. The
AAN reaches out to partner organizations for input on the measures, involves key stakeholders on the measure
development workgroups and posts the measures during a 30 day public comment period for comment by any
interested individual or group. For example, the DSP workgroup considered the addition of a measure on foot care
as it relates to distal symmetric polyneuropathy. The workgroup worked with the American Diabetes Association
(ADA) to develop this measure; however, ultimately this measure was not included in the measurement set as there
was significant overlap with the existing ADA measure.
Existing Quality Improvement (QI) Initiative or Collaborative for Measure Implementation

The American Academy of Neurology has developed a performance in practice program for maintenance of
certification (MOC), NeuroPI18, which meets the American Board of Psychiatry and Neurology (ABPN)
requirements for MOC Performance in Practice requirements. The NeuroPI will contain a new module for distal
symmetric polyneuropathy based upon the measures developed in this measurement set. The measures will be used
as the basis of the module content. A separate formal testing effort for reliability and validity is also planned for this
measurement set.
Technical Specifications Overview

The AAN develops technical specifications for multiple data sources, including:
• Electronic Health Record (EHR) Data
• Electronic Administrative Data (Claims)
• Expanded (multiple-source) Administrative Data
• Paper Medical Record/Retrospective Data Collection Flow Sheet
Because administrative claims are currently the only available sources of data, specifications to collect and report on
the neuropathy measures for administrative claims are included in this document.
The AAN is in the process of creating data elements required for electronic capture with Electronic Health Records
(EHRs). A listing of the data elements for each of the DSP measures will be made available at a later date.
Testing and Implementation of the Measurement Set

The measures in the set are being made available without any prior testing. The AAN welcomes the opportunity to
promote the initial testing of these measures and to ensure that any results available from testing are used to refine
the measures before implementation.

Desired Outcomes for Patients with DSP
Setting: Ambulatory and residential care (nursing facility, domiciliary, home care)
Processes . . . that link to . . . Outcomes
Establish and
define appropriate
Proposed diagnostic criteria
Process Measures
No Existing or
Proposed Measure: Promote appropriate Proposed
testing and studies Outcome
DSP Symptoms and Signs
Measures
Accurate and (see discussion
Proposed Measure: appropriate evaluation in the following
/monitoring of disease section, titled
Diabetes/Pre-Diabetes status and associated
Screening Screen for “DSP
symptoms to guide underlying causes
Outcomes”)
treatment options PATIENT of condition
Proposed Measure:
with DSP
Screening for Unhealthy
Alcohol Use
Assist patients in
managing pain and
Proposed Measure: improving quality of
Pain and Pain Interference life
with Function
Promote patient
Proposed Measure: safety and reduce
falls
Electrodiagnostic Studies
Proposed Measure: Enhancing patient Reduce DSP

safety and the
Querying about Falls complications
avoidance of adverse
events

Purpose of Measurement Set
The American Academy of Neurology (AAN) formed a Neuropathy Work Group to identify and define quality
measures towards improving outcomes for patients with distal symmetric polyneuropathy (DSP). The majority of
the available evidence that would meet a gap in care focused on distal symmetric polyneuropathy (DSP), therefore
this measurement set is focused on measures for patients with a diagnosis of DSP. The Work Group sought to
develop measures to support the delivery of high quality care for patients with DSP. The Work Group developed
measures that were focused on the gaps in care in need of significant improvement and the available rigorous
clinical evidence for DSP. The Work Group considered the development of outcome, process, structural,
composite, bundled, and group or system-level measures where it was appropriate.
The Work Group focused on measures that would be applicable to patients with an established diagnosis of distal
symmetric polyneuropathy. However, an important aspect of care is to ensure that an appropriate diagnosis of DSP
has been made. Thus there is a paired measure that focuses on ensuring that the appropriate diagnosis criteria were
followed and electrodiagnostic testing was completed.
Importance of Topic
Prevalence and Incidence
• DSP is the most common variety of neuropathy and a type of diabetic neuropathy.1,4
• Peripheral neuropathy is estimated to affect more than 20 million Americans.3 The overall prevalence is
approximately 2,400 (2.4%) per 100,000 population, but in individuals older than 55 years, the prevalence
rises to approximately 8,000 (8%) per 100,000.19,20 Older people are among the top spenders on healthcare.
They make up 13% of the US population in 2002, yet they consumed 63% of health care expenses.6
Improving the effectiveness of diagnosis and optimizing patient outcomes will become increasingly
important as the population of the United States ages.
• Neuropathies affect up to 50% of patients with diabetes.7 DSP affects at least one in four diabetic patients.1
Diabetes is one of the five major chronic conditions that affect 25% of the US community population14 and
amounted to more than $62.3 billion health care costs in 1996.9
• The incidence of DSP is 2% per year.6
Mortality and Morbidity

• Neuropathies also cause great morbidity because the symptoms severely decrease patients' quality of life.
The secondary complications of neuropathy such as falls, foot ulcers, cardiac arrhythmias, and ileus are
significant and can lead to fractures, amputations, and even death in patients with diabetes.7
• Pain associated with diabetic neuropathy exerts a substantial impact on the quality of life, particularly by
causing considerable interference in sleep and enjoyment of life.11 Despite this significant impact, 25% and
39% of the diabetic patients, respectively, had no treatment for their pain in two surveys.12,13
• Another complication in diabetic neuropathy is the development of foot ulcers, and some reports have
estimated that this occurs in approximately 2.5% of patients with diabetes.7
Office Visits and Hospital Stays

• The distal symmetric sensory or distal sensorimotor polyneuropathy represents the most relevant clinical
manifestation, affecting 30% of the hospital-based population and 25% of community-based samples of
diabetic patients.6
Family Caregiving
• Patients describe pain-related interference in multiple health related quality of life (HR-QOL) and functional
domains, as well as reduced ability to work and reduced mobility due to their pain. The substantial costs to
society of DSP derive from direct medical costs, loss of the ability to work, loss of caregivers' ability to work
and possibly greater need for institutionalization or other living assistance.10
Cost:
• A 1999 survey found that 8-9% of Medicare recipients have peripheral neuropathy as their primary or
secondary diagnosis.3 The annual cost to Medicare exceeds $3.5 billion.3
Opportunity for Improvement

• DSP is often difficult to diagnose reliably. It is often misdiagnosed or erroneously associated as the side
effect of another disease like kidney failure.3 Undiagnosed and untreated neuropathy may lead to disability
and poor quality of life. Neuropathy needs to be diagnosed early to prevent complications, such as
neuropathic pain or the diabetic foot.
• Since DSP is the major contributory factor for diabetic foot ulcers and the lower-limb amputation rates in
diabetic subjects are 15 times higher than in the non-diabetic population, an early detection of DSP by
screening and appropriate diagnosis is of utmost importance.15 This is even more imperative because many
patients with DSP are asymptomatic or have only mild symptoms.
• Neuropathic pain is often more difficult to treat than many other types of chronic pain. Patients with
neuropathic pain have great medical co-morbidity burden than age- and sex-adjusted controls.10 Data
collected between 1988 and 1995 (derived from the Center for Disease Control's population-based
Behavioral Risk Factor Surveillance System [BRFSS], as well as the National Health and Nutrition
Examination [NHANES] surveys) reveal significant quality gaps in the treatment of diabetes and in
screening for diabetes-related complications.7 Diabetics also do not receive appropriate screening measures:
only 55% obtain annual foot examinations.16
Disparities
• There is currently no consistent data that shows disparities between minorities and whites for diabetes-
related neuropathy and peripheral vascular disease.17 DSP is more common in older adults. Older people are
among the top spenders on healthcare. They make up 13% of the US population in 2002, yet they
consumed 63% of health care expenses.6 Improving the effectiveness of diagnosis and optimizing patient
outcomes will become increasingly important as the population of the United States ages.
• No definite racial predilection has been demonstrated for diabetic neuropathy. However, members of
minority groups (eg, Hispanics, African Americans) have more secondary complications from diabetic
neuropathy, such as lower-extremity amputations, than whites.17,21 They also have more hospitalizations for
neuropathic complications.
• Men with type 2 diabetes may develop diabetic polyneuropathy earlier than women, and neuropathic pain
causes more morbidity in women than in men.22
Clinical Evidence Base

Clinical practice guidelines and peer-reviewed consensus papers serve as the foundation for the development of
performance measures. There are relatively few guidelines that have been developed for distal symmetric
polyneuropathy. Guidelines or consensus papers from the American Academy of Neurology4,23-26, American
Diabetes Association27, United States Preventive Services Task Force28, National Quality Forum Consensus
Standards29, International Association for the Study of Pain (IASP) Neuropathic Pain Special Interest Group with
additional support provided by the Neuropathic Pain Institute30, and the American Geriatrics Society31 were used as
the foundation for the measures in this measurement set. In addition, recommendations from other groups were
considered including the American Association of Clinical Endocrinologists, European Federation of Neurological
Societies, American Association of Neuromuscular and Electrodiagnostic Medicine, American Association of
Physical Medicine and Rehabilitation, and the Peripheral Nerve Society.
Selected guidelines met all of the required elements outlined in the American Medical Association convened
Physician Consortium for Performance Improvement® framework for consistent and objective selection of clinical
practice guidelines from which measures may be derived.32
Distal Symmetric Polyneuropathy Outcomes

The work group attempted to develop measures of outcomes along with measures of processes that may improve
patient outcomes for DSP patients. Due to the lack of standardized diagnostics for DSP and measures already
developed by outside organizations for outcomes of untreated DSP (eg foot ulcerations), the work group felt there
were no specific outcomes that could be focused on. The Work Group decided to focus on performance measures
based upon processes that may achieve desired outcomes and reflect high quality care.
Desired outcomes for DSP include:

1. Establish and define appropriate DSP diagnostic criteria to ensure appropriate disease diagnosis
2. Promote appropriate testing and studies for DSP and related complications
3. Screen for underlying causes of DSP (diabetes, unhealthy alcohol use, etc.) to promote appropriate
treatment of DSP patients.
4. Assist patients in managing their pain and improving their quality of life
5. Promote patient safety and reduce falls
6. Reduce DSP complications (eg foot ulcers)
Intended Audience, Care Setting, and Patient Population

The AAN encourages use of the measures by physicians and other health care professionals, where appropriate, to
manage the care for all patients with distal symmetric polyneuropathy 18 years and older. These measures are
intended to be used to calculate performance or reporting at the practitioner level. Performance measurement may
not achieve the desired goal of improving patient care by itself. Measures have their greatest impact when they are
used appropriately and linked directly to operational steps that clinicians, patients, and health plans can apply in
practice to improve care.
Distal Symmetric Polyneuropathy Work Group Recommendations

The measurement set includes measures that focus on accurate and appropriate diagnosis of disease status and
associated symptoms to guide treatment, effective using of, improving quality of life, and enhancing patient safety.
The DSP Work Group identified several desired outcomes for patients with DSP (see “Link to Outcomes” diagram
in the preceding section). Current quality gaps in DSP care emphasize the need to improve specific processes that
have been demonstrated to improve DSP patient outcomes. As a result, many of the measures in the DSP
measurement set focus on the provision of effective and efficient patient-centered care. These performance
measures are designed for practitioner level quality improvement to achieve better outcomes for patients with DSP.
Unless otherwise indicated, the measures are also appropriate for accountability if the appropriate methodological,
statistical, and implementation rules are achieved.

Measures addressing appropriate diagnosis
Measure #2: Distal Symmetric Polyneuropathy (DSP) Diagnosis Criteria: Electrodiagnostic Studies
Measures addressing underuse of effective services (evaluation and treatment services)
Measure addressing quality of life/morbidity
Measures addressing safety
These measures are designed for individual practitioner level quality improvement. Unless otherwise indicated the
measures are appropriate for accountability if the appropriate methodological, statistical, and implementation rules
are followed.
Institute Of Medicine Domains of Health Care Quality

Effective Patient-
Measure Safe Underuse Overuse Centered Timely Efficient Equitable
Measure #1: Distal Symmetric Polyneuropathy
(DSP) Diagnosis Criteria: DSP Symptoms and X X X
Signs
Measure #2: Distal Symmetric Polyneuropathy
(DSP) Diagnosis Criteria: Electrodiagnostic X X X
Studies
Measure #3: Diabetes/Pre-diabetes Screening
for Patients with DSP X X X
Measure #4: Screening for Unhealthy Alcohol
Use X X X X
Measure #5: Querying about Pain and Pain
Interference with Function X X X X
Measure #6: Querying about Falls for Patients
with DSP X X X X
Where possible the measures in this measurement set were focused to address one or more of the IOM’s Domains of Health
Care Quality. Please refer to each measure for which domain(s) it addresses.
Other Potential Measures

The Work Group considered several other potential measures, though ultimately decided they were not appropriate
for inclusion in the measurement set.
Measure Harmonization
When existing measures are available for the same measurement topic, the AAN attempts to harmonize the
measures to the extent it is feasible. The AAN works to ensure there is no duplication of existing measures. The
AAN reaches out to partner organizations for input on the measures, involves key stakeholders on the measure
development workgroups and posts the measures during a 30 day public comment period for comment by any
interested individual or group. For example, the DSP workgroup considered the addition of a measure on foot care
as it relates to distal symmetric polyneuropathy. The workgroup worked with the American Diabetes Association
(ADA) to develop this measure; however, ultimately this measure was not included in the measurement set as there
was significant overlap with the existing ADA measure.
Potential for future measure development in the National Priorities Partnership Priority Areas
Care coordination: Multiple specialties treat patients with distal symmetric polyneuropathy. Care coordination
between primary care physicians, diabetes specialists, neurologists, physical therapists and many other clinicians is
paramount to providing optimal care to the patient with neuropathy.
Patient Safety: There are significant safety concerns associated with distal symmetric polyneuropathy. Neuropathy
often leads to the loss of feeling in feet, hands, and other parts of the body, and may lead to dizziness and impaired
balance. This may lead to significant falls risks and related safety issues. Medications used to treat neuropathies can
have side effects that need to be recognized and managed appropriately. Frequently, neuropathy is the first
symptom of an underlying disorder such as diabetes or nutritional deficiency. The early recognition of these
disorders is important not only to treat the neuropathy but also the underlying disorder.
Patient and family engagement: Involving patients in their own care, particularly with regard to education and self-
management, can improve health outcomes, as well as the patient's quality of life.8 Spouses of neuropathy patients
have been shown to have negative adverse outcomes socially because of their partner’s neuropathic pain.10
Involving both the patient and family members in the diagnosis and treatment of DSP may lead to improved quality
of life.
Palliative/End of Life Care: Ulcers or bed sores due to diabetes and diabetic neuropathy are a significant issue for
patients with DSP. In the future, there may be the potential to create a measure to focus on this end of life issue for
DSP patients. Pain management is an integral part of neuropathy treatment.
Existing Quality Improvement (QI) Initiative or Collaborative for Measure Implementation

The American Academy of Neurology has developed a performance in practice program for maintenance of
certification (MOC), NeuroPI18, which meets the American Board of Psychiatry and Neurology (ABPN)
requirements for MOC Performance in Practice requirements. The NeuroPI will contain a new module for distal
symmetric polyneuropathy based upon the measures developed in this measurement set. The measures will be used
as the basis of the module content. A separate formal testing effort for reliability and validity is also planned for this
measurement set.
Technical Specifications: Overview

The AAN develops technical specifications for multiple data sources, including:
• Electronic Health Record (EHR) Data
• Electronic Administrative Data (Claims)
• Expanded (multiple-source) Administrative Data
• Paper Medical Record/Retrospective Data Collection Flow Sheet
Because administrative claims are currently the only available sources of data, specifications to collect and report on
the DSP measures for administrative claims are included in this document.
The AAN is in the process of creating data elements required for electronic capture with Electronic Health Records
(EHRs). A listing of the data elements for each of the DSP measures will be made available at a later date.
Measure Exceptions
For process measures, the AAN follows the PCPI’s three categories of reasons for which a patient may be excluded
from the denominator of an individual measure:
• Medical reasons (examples)
- not indicated (absence of organ/limb, already received/performed, other)
- contraindicated (patient allergic history, potential adverse drug interaction, other)
• Patient reasons (examples)
- patient declined
- social or religious reasons
- other patient reasons
• System reasons (examples)
- resources to perform the services not available
- insurance coverage/payor-related limitations
- other reasons attributable to health care delivery system
These measure exception categories are not available uniformly across all measures; for each measure, there must be
a clear rationale to permit an exception for a medical, patient, or system reason. For some measures, examples have
been provided in the measure exception language of instances that would constitute an exception. Examples are
intended to guide clinicians and are not all-inclusive lists of all possible reasons why a patient could be excluded
from a measure. The exception of a patient may be reported by appending the appropriate modifier to the CPT
Category II code designated for the measure:
• Medical reasons: modifier 1P
• Patient reasons: modifier 2P
• System reasons: modifier 3P
Although this methodology does not require the external reporting of more detailed exception data, the AAN
follows the PCPI’s recommendation that physicians document the specific reasons for exception in patients’ medical
records for purposes of optimal patient management and audit-readiness.32 The PCPI also advocates the systematic
review and analysis of each physician’s exceptions data to identify practice patterns and opportunities for quality
improvement. For example, it is possible for implementers to calculate the percentage of patients that physicians
have identified as meeting the criteria for exception.
Please refer to documentation for each individual measure for information on the acceptable exception categories
and the codes and modifiers to be used for reporting.
Testing and Implementation of the Measurement Set

The draft measures in the set were made available for public comment without any prior testing. The AAN
recognizes the importance of testing all of its measures and encourages testing of the DSP measurement set for
feasibility and reliability by organizations or individuals positioned to do so. The AAN welcomes the opportunity to
promote the initial testing of these measures and to ensure that any results available from testing are used to refine
the measures before implementation.

This is a paired measure with measure #2.
Measur e Description
Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had their neuropathic
symptoms and signs* reviewed and documented at the initial evaluation for distal symmetric polyneuropathy.
*Neuropathicsymptoms: numbness, altered sensation, or pain in the feet. Neuropathic Signs: decreased or absent ankle reflexes,
decreased distal sensation, and distal muscle weakness or atrophy.
Measur e Components
Numerator Patients who had their neuropathic symptoms and signs* reviewed and documented at the initial
Statement evaluation for distal symmetric polyneuropathy.
Definitions:
*Neuropathic Symptoms: numbness, altered sensation, or pain in the feet.
Neuropathic Signs: decreased or absent ankle reflexes, decreased distal sensation, and distal muscle
weakness or atrophy
Denominator All patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy.
Statement
Denominator • Documentation of a medical reason for not reviewing and documenting neuropathic
Exceptions symptoms and signs (eg, patient has profound mental retardation, patient has a language
disturbance, or patient is cognitively impaired)
Supporting The following evidence statements are quoted verbatim from the referenced clinical guidelines:
Guideline & • Symptoms alone have relatively poor diagnostic accuracy in predicting the presence of
Other polyneuropathy. Multiple neuropathic symptoms are more accurate than single
References symptoms and should be weighted more heavily. (Level B) 23
• Signs are better predictors of polyneuropathy than symptoms and should be weighted
more heavily. (Level B)23
• A single abnormality upon examination is less sensitive than multiple abnormalities in
predicting the presence of polyneuropathy; therefore, an examination for
polyneuropathy should look for a combination of signs. (Level B)23
• Relatively simple examinations are as accurate in diagnosing polyneuropathy as complex
scoring systems; therefore, the case definition can use simple examinations without
compromising accuracy. (Level B)23
• The combination of neuropathic symptoms, signs, and abnormal electrodiagnostic
studies provides the most accurate diagnosis of distal symmetric polyneuropathy.
(Formal Consensus )23
Measur e Importan ce
Relationship to Appropriate diagnosis of DSP can lead to improved patient outcomes and can prevent
desired complications (i.e., neuropathic pain). The accurate criteria for the diagnosis of DSP in
outcome debatable. The exact criteria for diagnosis are needed to aid clinicians in the diagnosis of DSP.
Distal symmetric polyneuropathy can be asymptomatic in its early stages. Asymptomatic

detection is more likely when dyskinesia or parasthesias are lacking or when only motor
deficits are the presenting factors. There are many signs that need to be examined including
primary sensory modalities, examining for sensory motor loss, and examining for motor
signs.23
Neuropathy is often misdiagnosed or not diagnosed at all due to a misunderstanding or lack of
presentation of symptoms; it can be mistaken for another condition. This leads to a delay in
treatment or no treatment at all for those afflicted by the condition.3
Correct diagnosis may reduce hospitalizations for neuropathic complications, lower morbidity
in females, slow or control the progression of neuropathy in diabetics, and reduce variability in
symmetric diabetic polyneuropathy prevalence data. Peripheral neuropathy has not been
adequately recognized. It is often misdiagnosed or erroneously associated as the side effect of
another disease like kidney failure.3
DSP is one of the most common neurological complications of HIV/AIDS and its
treatment.33
Clinicians caring for patients with HIV infection need recognize the importance in becoming
familiar with the diagnosis and treatment of DSP34, as this may provide significant
improvement in the quality of life in these patients.
Opportunity for The lack of consistent criteria for diagnosis of DSP has supported a wide variability in
Improvement prevalence data for the condition. Moreover, because many patients with DSP are initially
asymptomatic, detection is extremely dependent on careful neurologic examination by the
primary care clinician or other provider.
Peripheral neuropathy is estimated to affect more than 20 million Americans.3 1 in 3 patients

with diabetes are affected by DSP.35 Neuropathy is estimated to be present in 7.5% of patients
at the time of diabetes diagnosis. More than half of cases are distal symmetric
polyneuropathy.35
Approximately 30% of neuropathies are caused by diabetes and 30% are idiopathic (or
unknown cause).1 Other common causes of neuropathy include autoimmune disorders,
tumors, hereditary conditions, nutritional imbalances, infections or toxin.
IOM Domains • Safe

of Health Care • Effective
Quality • Efficient
Addressed
Exception Evaluation for neuropathy involves taking a patient history regarding symptoms of pain,
Justification numbness, tingling, weakness, balance impairment etc. The neurological exam of these
patients includes sensory testing where patient input regarding reduced sensation and co-
operation for motor testing is required in addition to objective evidence of atrophy or reflex
loss which can be detected by the examiner. In patients who are profoundly mentally retarded,
have language impairments (eg aphasia), or other significant cognitive impairment they cannot
provide the required information for diagnosis of distal symmetric polyneuropathy.
Harmonization There are no other measures currently available that are similar to this measure or need to be
with Existing harmonized with this measure.
Measures
Measur e Designation
Measure purpose • Quality improvement
• Accountability
Type of measure • Process
Level of • Individual practitioner
Measurement

Care setting • Ambulatory care
Data source • Electronic health record (EHR) data
• Administrative Data/Claims (outpatient claims)
• Administrative Data/Claims Expanded (multiple-source)
• Paper medical record
Technical Specifications: Administrative/Claims Data

Administrative claims data collection requires users to identify the eligible population (denominator) and
numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based
on all patients in a given practice for whom data are available and who meet the eligible
population/denominator criteria.
The specifications listed below are those needed for performance calculation. Additional CPT II codes may
be required depending on how measures are implemented in reporting programs versus performance
assessment programs.
Denominator All patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy
(Eligible
Population) ICD-9 –CM Diagnosis Codes:
250.6, 250.60, 250.61, 250.62, 250.63, 356.4, 356.8, 356.9, 357.1, 357.2, 357.3, 357.4,
357.5, 357.6, 357.7, 357.8, 357.89, 357.9
AND
CPT E/M Service Code:
99201, 99202, 99203, 99204, 99205 (office-new patient),
99211,99212, 99213, 99214, 99215 (office-established patient),
99241, 99242, 99243, 99244, 99245 (outpatient consult),
99304, 99305, 99306, 99307, 99308, 99309, 99310 (nursing facility),
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 (domiciliary),
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (home visit).
Numerator Patients who had their neuropathic symptoms and signs* reviewed and documented at
the initial evaluation for distal symmetric polyneuropathy.
Definitions:
*Neuropathic Symptoms: numbness, altered sensation, or pain in the feet.
Neuropathic Signs: decreased or absent ankle reflexes, decreased distal sensation, and
distal muscle weakness or atrophy.
Reporting Instructions:
 For all patients meeting the denominator criteria, report either 1119F for initial
evaluation for condition or 1501F for not initial evaluation for condition.
 When 1119F is reported, also report the CPT Category II, 1500F Signs and symptoms
of distal symmetric polyneuropathy reviewed and documented.
1500F Symptoms and signs of distal symmetric polyneuropathy reviewed and documented
1119F Initial evaluation for condition
1501F Not initial evaluation for condition
Exceptions • Documentation of a medical reason(s) for not reviewing and documenting
neuropathic symptoms and signs (eg profound mental retardation, patient has
a language disturbance, or patient cognitively impaired)
• For patient with appropriate exclusion criteria, report 1500F-1P.

Measure #2: Distal Symmetric Polyneuropathy (DSP) Diagnosis Criteria-Electrodiagnostic Studies
This is a paired measure with measure #1.
Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had electrodiagnostic
studies (EDX) conducted, documented and reviewed within 6 months of initial evaluation for distal symmetric
polyneuropathy.
Measur e Components
Numerator Patients who had electrodiagnostic (EDX) studies conducted, documented, and reviewed
Statement within 6 months of initial evaluation for distal symmetric polyneuropathy.
Note: It may be necessary to look for findings in the patient medical record or request studies
previously conducted from another physician office which may require additional time.
Another electrodiagnostic study should not be performed if a satisfactory study has already
been done and can be reviewed.
Statement
Denominator • Documentation of a medical reason for not conducting, documenting and reviewing
Exceptions EDX studies (eg patient has a skin conditions which contraindicates EDX)
• Documentation of a patient reason for not conducting, documenting and reviewing
EDX studies (eg patient declines to undergo testing)
• Documentation of a system reason for not conducting, documenting and reviewing
EDX studies (eg patient does not have insurance to pay for the testing)
Supporting The following evidence statements are quoted verbatim from the referenced clinical
Guideline & guidelines or consensus papers:
Other References • The combination of neuropathic symptoms, signs, and abnormal electrodiagnostic
studies provides the most accurate diagnosis of distal symmetric polyneuropathy.
(Formal Consensus)23
• Electrodiagnostic studies are recommended as part of the clinical research case
definition since they are objective and validated tests of peripheral nerve function.
Abnormal electrodiagnostic studies increase the likelihood of the presence of distal
symmetric polyneuropathy and provide a higher level of specificity to the case
definition. Electrodiagnostic studies should not be used alone to make the diagnosis
since their sensitivity and specificity are not perfect. (Formal Consensus).23
• The simplified minimal requirements for Nerve Conduction Study (NCS) protocol is
as follows:
1. Sural sensory and peroneal motor NCSs are performed in one lower
extremity. Taken together, these NCSs are the most sensitive for detecting a
distal symmetric polyneuropathy. If both studies are normal, there is no
evidence of typical distal symmetric polyneuropathy. In such a situation, no
further NCSs are necessary.(Formal Consensus)23
2. If sural sensory or peroneal motor NCSs are abnormal, the performance of
additional NCSs is recommended. This should include NCS of at least the
ulnar sensory, median sensory, and ulnar motor nerves in one upper
extremity. A contralateral sural sensory and one tibial motor NCS may also
be performed according to the discretion of the examiner. Caution is

warranted when interpreting median and ulnar studies since there is a
possibility of abnormality due to compression of these nerves at the wrist or
ulnar neuropathy at the elbow. (Formal Consensus)23
3. If a response is absent for any of the nerves studied (sensory or motor, a
NCS of the contralateral nerve should be performed. (Formal Consensus)23
4. If a peroneal motor response is absent, an ipsilateral tibial motor NCS
should be performed.(Formal Consensus)23
• Electrodiagnostic studies are not required for field or epidemiologic studies, but the
likelihood of diagnosis must be downgraded accordingly. (Formal Consensus)23
Relationship to Appropriate diagnosis is critical to ensuring that the patient receives the best possible
desired treatment. Electrodiagnostic studies are one of the three main criteria used for the most
outcome accurate diagnosis of distal symmetric polyneuropathy. Electrodiagnostic studies provide a
higher level of specificity for the diagnosis.36-39 Electrodiagnostic studies are sensitive,
specific, and validated measures of the presence of polyneuropathy.23
Opportunity for Gorson and Ropper40 found that electrodiagnostic studies, specifically, nerve conduction
Improvement studies showed a distal, axonal loss pattern affecting predominantly sensory fibers in the
majority of patients studied. However, nine of 98 patients (9%) had three or more
demyelinating features, and 6% had conduction block. These findings are virtually identical to
a previous study of diabetic polyneuropathy,41 but lower compared to another study (17%).42
This discrepancy may be related to patient selection. In the latter study patients were selected
from electrodiagnostic records without considering the clinical phenotype.16 Nonetheless,
because some patients may have an immune demyelinating neuropathy detected only by
electrodiagnostic evaluation24,43, electrodiagnostic studies remain an integral element of the
evaluation of diabetic patients with DSP.
Approximately 55% of patients have a potential for other causes of DSP with 9% having 3 or
more demyelinating features found on an EMG study.42

Addressed
Exception If patients have a severe neuropathy clinically in the presence of an apparent cause, the
Justification electrodiagnostic studies may not add additional information (medical exception). The
patients have the right to refuse any testing (patient exception) or decline the testing for
financial or other related reasons (system exception).
Measures
• Accountability
Measurement

Denominator All patients age 18 years and older with a diagnosis of distal symmetric
(Eligible polyneuropathy.
Population)
ICD-9 –CM Diagnosis Codes:
250.60, 250.61, 250.62, 250.63, 356.4, 356.8, 356.9, 357.1, 357.2, 357.3, 357.4, 357.5,
357.6, 357.7, 357.8, 357.89, 357.9
AND
99211, 99212, 99213, 99214, 99215 (office-established patient),
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 (domiciliary),
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (home visit)
Numerator Patients who had electrodiagnostic (EDX) studies conducted, documented, and
reviewed within 6 months of initial evaluation for distal symmetric polyneuropathy
Note: It may be necessary to look for findings in the patient medical record or request
studies previously conducted from another physician office which may require
additional time. Another electrodiagnostic study should not be performed if a
satisfactory study has already been done and can be reviewed.
 For all patients meeting the denominator criteria, report either 3751F,
Electrodiagnostic studies for distal symmetric polyneuropathy conducted (or requested),
documented, and reviewed within 6 months of initial evaluation for condition or 3752F
Electrodiagnostic studies for distal symmetric polyneuropathy not conducted (or requested),
documented, or reviewed within 6 months of initial evaluation for condition or 3753F Patient
has clear clinical symptoms and signs that are highly suggestive of neuropathy AND cannot be
attributed to another condition, AND has an obvious cause for the neuropathy
3751F Electrodiagnostic studies for distal symmetric polyneuropathy conducted (or requested),
documented, and reviewed within 6 months of initial evaluation for condition
3752F Electrodiagnostic studies for distal symmetric polyneuropathy not conducted (or requested),
documented, or reviewed within 6 months of initial evaluation for condition
3753F Patient has clear clinical symptoms and signs that are highly suggestive of neuropathy AND
cannot be attributed to another condition, AND has an obvious cause for the neuropathy

Exceptions • Documentation of a medical reason for not conducting, documenting and
reviewing EDX studies (eg patient has clear clinical symptoms and signs that
are highly suggestive of neuropathy AND cannot be attributed to another
condition, AND has an obvious cause for the neuropathy; OR has skin
conditions which contraindicate EDX)
• Append modifier to CPT II code: 3751F-1P
• Documentation of a patient reason for not conducting, documenting and
reviewing EDX studies (eg patient declines to undergo testing)
o Append modifier to CPT II code: 3751F-2P
• Documentation of a system reason for not conducting, documenting and
reviewing EDX studies (eg patient does not have insurance to pay for the
testing)

Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who had screening tests for
diabetes (eg fasting blood sugar test, a hemoglobin A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested or ordered
when seen for an initial evaluation for distal symmetric polyneuropathy.
Measur e Components
Numerator Patients who had screening tests for diabetes (eg, fasting blood sugar test, hemoglobin A1C,
Statement or a 2 hour Glucose Tolerance Test) reviewed, requested, or ordered when seen for an initial
evaluation for distal symmetric polyneuropathy.
Statement
Denominator • Documentation of a medical reason for not reviewing, requesting or ordering
Exceptions diabetes screening tests (eg patient has a diagnosis of diabetes, patient has a known
medical condition to cause neuropathy, patient had previous diabetes screening)
• Documentation of a patient reason for not reviewing, requesting or ordering
diabetes screening tests (eg patient declines to undergo testing)
• Documentation of a system reason for not reviewing, requesting or ordering
diabetes screening tests (eg patient does not have insurance to pay for testing)
Guideline & guidelines:
Other References • Screening laboratory tests may be considered for all patients with polyneuropathy. (Level
C) 27
• Those tests that provide the highest yield of abnormality are blood glucose, serum B12
with metabolites (methylmalonic acid with or without homocysteine), and serum protein
immunofixation electrophoresis. (Level C)27
• If there is no definite evidence of diabetes mellitus by routine testing of blood glucose,
testing for impaired glucose tolerance may be considered in distal symmetric sensory
polyneuropathy. (Level C) 27
• All patients should be screened for distal symmetric polyneuropathy(DSP) at diagnosis
and at least annually thereafter, using simple clinical tests. (Level B)24
Relationship to Early intervention and control of diabetes in DSP patients can improve care. DSP patients
desired screened for pre-diabetes or diabetes may reduce complications over time. Patients with
outcome painful diabetic neuropathy sensory polyneuropathy are more likely to have impaired glucose
tolerance tests (GTT) than those with painless sensory polyneuropathy.44
DSP is the most common variety of neuropathy and type of diabetic neuropathy.1.4
Approximately 30% of neuropathies are caused by diabetes.3 Neuropathies affect up to 50%
of patients with diabetes.7 Since DSP is the major contributory factor for diabetic foot ulcers
and the lower-limb amputation rates in diabetic subjects are 15 times higher than in the non-
diabetic population, an early detection of DSP by screening and appropriate diagnosis is of
utmost importance.15
Opportunity for Approximately 1.9 million people 20 years and older were newly diagnosed with diabetes in
Improvement 2010. In 2005–2008, based on fasting glucose or hemoglobin A1c levels, 35% of U.S. adults
aged 20 years or older had pre-diabetes (50% of adults aged 65 years or older). Applying this
percentage to the entire U.S. population in 2010 yields an estimated 79 million American
adults aged 20 years or older with prediabetes.44
DSP affects at least one in four diabetic patients.1 Diabetes is one of the five major chronic
conditions that affect 25% of the US community population14 and amounted to more than
$62.3 billion health care costs in 1996.9
Data collected between 1988 and 1995 (derived from the Center for Disease Control's
population-based Behavioral Risk Factor Surveillance System [BRFSS], as well as the National
Health and Nutrition Examination [NHANES] surveys) reveal significant quality gaps in the
treatment of diabetes and in screening for diabetes-related complications.7 Diabetics also do
not receive appropriate screening measures: only 55% obtain annual foot examinations.16
The UK Prospective Diabetes Study showed the effects of different treatment therapies and
the associated outcomes over time. The group studied the effects of diet alone and
deterioration of glycemic control; this shows the importance of early intervention and control
of diabetes.45

Addressed
Exception If patients already have an underlying diagnosis of diabetes, the testing would include
Justification evaluation of degree of glycemic control, rather than tests for initial diagnosis of diabetes. If
patients have already been diagnosed with diabetes, has a diagnosed cause of their neuropathy
or has previously completed testing they do not need to undergo additional testing as this
would be unnecessary. Patients have a right to refuse testing for personal (patient exception)
or financial reasons (system exception).
Measures
• Accountability
Measurement


Population)
356.4, 356.9, 357.1, 357.2, 357.3, 357.4, 357.5, 357.6, 357.7, 357.8, 357.89, 357.9,
AND
99211, 99212, 99213, 99214, 99215 (office-established patient),
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 (domiciliary),
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (home visit)
Numerator Patients who had screening tests for diabetes (eg, fasting blood sugar test, hemoglobin
A1C, or a 2 hour Glucose Tolerance Test) reviewed, requested, or ordered when seen
for an initial evaluation of distal symmetric polyneuropathy.
• For all patients meeting the denominator criteria, report CPT Category II code
1119F, initial evaluation for condition or 1501F, not initial evaluation for condition.
• When 1119F is reported, also report 3754F Screening tests for diabetes mellitus
reviewed, requested, or ordered.
•
3754F Screening tests for diabetes mellitus reviewed, requested, or ordered
Exceptions polyneuropathy.
• Documentation of a medical reason for not reviewing, requesting or ordering
diabetes screening tests (eg patient already had diagnosis of diabetes or patient
has a known medical condition to cause neuropathy, patient had previous
diabetes screening)
o Append modifier to CPT II code: 3754F -1P
• Documentation of a patient reason for not reviewing, requesting or ordering
diabetes screening tests (eg patient declines to undergo testing)
• Documentation of a system reason for not reviewing, requesting or ordering
diabetes screening tests (eg patient does not have insurance to pay for testing)

Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who were screened with a
validated screening instrument for unhealthy alcohol use* when seen for an initial evaluation for distal symmetric
polyneuropathy.
*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories representing unhealthy alcohol use
include risky use, problem drinking, harmful use, and alcohol abuse, and the less common but more severe alcoholism and alcohol dependence.
Measur e Components
Numerator Patients who were screened with a validated screening instrument for unhealthy alcohol use*
Statement when seen for an initial evaluation for distal symmetric polyneuropathy.
*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health. Categories
representing unhealthy alcohol use include risky use, problem drinking, harmful use, and alcohol abuse, and
the less common but more severe alcoholism and alcohol dependence.
Unhealthy alcohol use can be assessed using one of a number of available valid and reliable
instruments available from medical literature. Examples include, but are not limited to:
• CAGE-AID (Cut-down, Annoyed, Guilty, Eye-opener)46
• AUDIT C (Alcohol Use Disorders Identification Test – Consumption)41
A systematic method of assessing for unhealthy alcohol use should be utilized. Please refer to
the National Institute on Alcohol Abuse and Alcoholism publication: Helping Patients Who
Drink Too Much: A Clinician’s Guide for additional information regarding systematic screening
methods.47
Statement
Denominator • Documentation of a medical reason for not screening the patient with a validated
Exceptions screening instrument for unhealthy alcohol use (eg patient diagnosed with
alcoholism)
• Documentation of a patient reason for not screening the patient with a validated
screening instrument for unhealthy alcohol use (eg patient declines to answer
questions/complete the screening)
Guideline & guidelines or consensus papers.
Other References • The USPSTF strongly recommends screening and behavioral counseling interventions to
reduce alcohol misuse by adults, including pregnant women, in primary care settings. (Level
B)28
• During new patient encounters and at least annually, patients in general and mental
healthcare settings should be screened for at-risk drinking, alcohol use problems and
illnesses, and any tobacco use. (Consensus Standard)29
• All patients identified with alcohol use in excess of National Institute on Alcohol Abuse
and Alcoholism guidelines and/or any tobacco use should receive brief motivational
counseling intervention by a healthcare worker trained in this technique. (Consensus
Standard)29
Relationship to Reduction in alcohol dependence varies with referral for treatment. Alcohol dependence
desired often goes undetected and in a recent study in primary care patients with alcohol dependence,
outcome they received the recommended quality of care including a referral for treatment
approximately 10% of the time.48
Chronic unhealthy alcohol use leads to metabolic changes of nerve cells, these metabolic
changes lead to break down in the nerve cells which in turn cause neuropathies in patients
who chronically misuse alcohol. It is therefore important to monitor patients for alcohol
consumption and misuse.47
Epidemiological data indicate that not only increased alcohol consumption but also the
traditional cardiovascular risk factors such as hypertension, smoking, and cholesterol play a
role in development and progression of diabetic neuropathy and hence need to be prevented
or treated.1
Opportunity for In patients with alcohol dependence, only 10% received the recommended quality of care
Improvement including a referral for treatment.48 Unhealthy alcohol use can be assessed using one of a
number of available valid and reliable instruments available from medical literature. Examples
include, but are not limited to: CAGE-AID46 and Audit C (Alcohol Use Disorders
Identification Test – Consumption).41

Addressed
• Patient-Centered
Exception In patients with documented alcoholism, it would be unnecessary to rescreen them for
Justification unhealthy alcohol use. Patients may refuse to be screened (patient exception) for unhealthy
alcohol use.
Harmonization There is one other measure that refers to screening for unhealthy alcohol use. This measure
with Existing has been adapted to capture those patients with a diagnosis of distal symmetric
Measures polyneuropathy screened for unhealthy alcohol use as these patients are not necessarily
captured by the existing screening measures for unhealthy alcohol use. Existing literature
supports specifically screening these patients for this condition. The existing PCPI measure is
a general measure meant to be used for all patients 18 years or older, this measure applies to
those diagnosed with distal symmetric polyneuropathy due to risk identified for these
patients.
• Accountability
Measurement
Population)
250.60, 250.61, 250.62, 250. 63, 356.4, 356.9, 357.1, 357.2, 357.3, 357.4, 357.5, 357.6,
357.7, 357.8, 357.89, 357.9
AND
99212, 99213, 99214, 99215 (office-established patient),
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 (domiciliary),
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (home visit),
Numerator Patients who were screened with a validated screening instrument for unhealthy
alcohol use* when seen for an initial evaluation for distal symmetric polyneuropathy.
*Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health.
Categories representing unhealthy alcohol use include risky use, problem drinking, harmful use, and
alcohol abuse, and the less common but more severe alcoholism and alcohol dependence.
Unhealthy alcohol use can be assessed using one of a number of available valid and
reliable instruments available from medical literature. Examples include, but are not
limited to:
• CAGE-AID (Cut-down, Annoyed, Guilty, Eye-opener)46
• AUDIT C (Alcohol Use Disorders Identification Test – Consumption)41
A systematic method of assessing for unhealthy alcohol use should be utilized. Please
refer to the National Institute on Alcohol Abuse and Alcoholism publication: Helping
Patients Who Drink Too Much: A Clinician’s Guide for additional information regarding
systematic screening methods.
1119F, initial evaluation for condition or 1501F, not initial evaluation for condition.
• When 1119F is reported, also report 3061F, Patient screened for unhealthy alcohol
use using a systematic screening method
3016F Patient screened for unhealthy alcohol use using a systematic screening method
• Documentation of a medical reason for not screening the patient with a
validated screening instrument for unhealthy alcohol use (eg patient diagnosed
with alcoholism)
• Documentation of a patient reason for not screening the patient with a
validated screening instrument for unhealthy alcohol use (eg patient declines
to answer questions/complete the screening)

Percentage of patient visits for patient age 18 years and older with a diagnosis of distal symmetric polyneuropathy who was
queried about pain and pain interference with function using a valid and reliable instrument.
Measur e Components
Numerator Patient visits with the patient queried about pain and pain interference with function using a
Statement valid and reliable instrument (eg Graded Chronic Pain Scale).
Note: Neuropathic pain can be assessed using one of a number of available valid and reliable
instruments available from medical literature. Examples include, but are not limited to:
• Graded Chronic Pain Scale49
Denominator All visits for patients age 18 years and older with a diagnosis of distal symmetric
Statement polyneuropathy.
Denominator • Documentation of a medical reason for not querying the patient about pain and pain
Exceptions interference with function (eg patient cognitively impaired and unable to respond)
• Documentation of a patient reason for not querying the patient about pain and pain
interference with function (eg patient declines to respond to questions)
Other References • Assessment of neuropathic pain (NP) should focus on identifying and treating the
underlying disease processes and peripheral or central nervous system lesions, response to
prior therapies, and comorbid conditions that can be affected by therapy. Particular
attention should be paid to identifying coexisting depression, anxiety, sleep disturbances,
and other adverse impacts of NP on health-related quality of life, and both pain and its
adverse effects should be reassessed frequently. Patient education and support are critical
components of the successful management of NP. Careful explanation of the cause of NP
and the treatment plan are essential. Patient and provider expectations regarding treatment
effectiveness and tolerability must be discussed, and realistic treatment goals should be
established with patients.(Strength not available)30
Relationship to Treatment of chronic painful diabetic neuropathy remains a challenge for physicians as
desired individual tolerability remains a major aspect in any treatment decision.1 In the case of painful
outcome diabetic neuropathy it is a chronic disease that is often treated with analgesics, there is little
data regarding the efficacy of any chronic treatment regimen. Improved patient outcomes and
preventing complications such as neuropathic pain and complications such as microvascular
diabetic neuropathy may significantly improve the quality of life in certain populations.
Patients with severe pain may present with very few clinical symptoms which can lead often
lead to a misdiagnosis or under-diagnosis, persistent pain over time can lead to disability and
impaired quality of life.1
The use of a valid and reliable assessment instrument for neuropathic pain may prevent
complications and improve the patient’s quality of life.1
Opportunity for At least one of four diabetic patients is affected by distal symmetric polyneuropathy1, which

Improvement represents a major health problem, since it may present with partly excruciating neuropathic
pain and is responsible for substantial morbidity, increased mortality, and impaired quality of
life.
Addressed
Exception In patients who are cognitively impaired, it may not be possible to obtain this information
Justification (medical exception). Patients may also refuse to answer questions about pain and function
(patient exception).
Measures
• Accountability
Measurement

Population)
250.60, 250.61, 250.62, 250. 63, 356.4, 356.9, 357.1, 357.2, 357.3, 357.4, 357.5, 357.6,
357.7, 357.8, 357.89, 357.9
AND
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 (domiciliary),
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (home visit)

Numerator Patient visits with the patients queried about pain and pain interference with function
using a valid and reliable instrument (eg Graded Chronic Pain Scale).
Note: Neuropathic pain can be assessed using one of a number of available valid and
reliable instruments available from medical literature. Examples include, but are not
limited to: Graded Chronic Pain Scale49
1502F, Patient queried about pain and pain interference with function using a valid and
reliable instrument.
1502F Patient queried about pain and pain interference with function using a valid and
reliable instrument
• Documentation of a medical reason for not querying the patient about pain
and pain interference with function (eg patient cognitively impaired and
unable to respond)
o Append modifier to CPT II code: 1502-1P
• Documentation of a patient reason for not querying the patient about pain
and pain interference with function (eg patient declines to respond to
questions)
o Append modifier to CPT II code: 1502-2P

Percentage of patients age 18 years and older with a diagnosis of distal symmetric polyneuropathy who were queried at least
once annually about falls within the past 12 months and the response was documented.
Measur e Components
Numerator Patients who were queried at least once annually about falls within the past 12 months
Statement
Note: Participants are encouraged to use validated assessments. An example of this is the
multifactorial falls risk assessment, which is to be performed once a year as part of an exam.31
Statement
Denominator • Documentation of a medical reason for not querying the patient about falls within
Exceptions the past 12 months(eg patient is cognitively impaired and unable to communicate,
patient is non-ambulatory)
• Documentation of a patient reason for not querying the patient about falls within the
past 12 months (eg patient declines to answer the query about falls)
Other References • An increased risk of falls is also probable among patients with Parkinson disease,
peripheral neuropathy, lower extremity weakness or sensory loss, and substantial loss of
vision (Level B).26
• All of the patients with any fall risk factors described above should asked about falls
during the past year (Level A)26
• After a comprehensive standard neurologic examination, including an evaluation of
cognition and vision, if further assessment of the extent of fall risk is needed, other
screening measures to be considered include the Get-Up-And-Go Test or Timed Up-
and-Go Test, an assessment of ability to stand unassisted from a sitting position, and the
Tinetti Mobility Scale (Level B).26
• An increased risk of falls is established among persons with diagnoses of stroke,
dementia, disorders of gait and balance, and those who use assistive devices to ambulate
(Level A).26
• As for screening measures that may predict or further assess fall risk, a history of recent
falls is an established predictor of future falls (Level A).26
• Additional screening instruments of probable value include the Get-Up-And-Go Test or
Timed Up-and-Go Test, an assessment of ability to stand from a sitting position, and the
Tinetti Mobility Scale (Level B). 26
• Other screening instruments of possible utility are described in appendix e-4 (Level C).31
• Direct interventions customized to the identified risk factors, coupled with an appropriate
exercise program should follow the multifactorial fall risk assessment.(Level A)31
• A strategy to reduce the risk of falls should include multifactorial assessment of known
fall risk factors and management of the risk factors identified. (Level A)31
Measure Importance
Relationship to Diabetic peripheral neuropathy causes loss of distal strength and sensation with interruption

desired of both afferent and efferent pathways. The postural instability associated with diabetic
outcome peripheral neuropathy is most apparent in unipedal stance and balance – both of which are
critical in gait and activities of daily living such as changing clothes and climbing stairs.
No associated co-morbidities explained the high rate of falls among the elderly with peripheral
neuropathy suggesting there is a risk factor for falls among the elderly with peripheral
neuropathy.50 Fall risk assessment and plan of care tools reduce the risk of falls among older
adults in the community.26,51
Opportunity for Fall risk assessments and plans of care reduce risk of falls among older adults. Falls are a
Improvement recognized as an important cause of morbidity and mortality in the elderly – costing the health
care system millions of dollars each year.50 Almost one-third of those over age 65 and not in a
nursing home fall each year. Much work has been done to identify risk factors that contribute
to falls. An important risk factor that has been identified and is increasingly more prevalent is
diabetic peripheral neuropathy.
One retrospective study by Cavanagh et al. found that diabetic neuropathic subjects were 15
times more likely to report injury and felt significantly less safe during standing and walking
than non-neuropathic subjects.52 Another study by Richardson et. al. found diabetics with
EMG-confirmed peripheral neuropathy were 23 times more likely to report instability
resulting in a fall or injury.53

Addressed
Exception A patient that is non-ambulatory (eg wheel chair bound, amputee, or paralyzed) or patients
Justification that are unable to communicate or decline to communicate would be excluded from this
measure as the querying of the patient is driven by their mobility condition or ability to
communicate (medical exception) and willingness to communicate (patient exception).
Harmonization The AAN attempts to harmonize with existing measures, this measure has been adapted to
with Existing capture those patients with a diagnosis of distal symmetric polyneuropathy screened for falls.
Measures The measure has also been adapted to account for additional screening not captured in
existing falls measures. This measure specifically does NOT have an upper age limit that is
associated with other falls measures from the American Geriatrics Society.
• Accountability
Measurement

Population)
ICD-9–CM Diagnosis Codes:
250.60, 250.61, 250.62, 250.63, 356.4, 356.9, 357.1, 357.2, 357.3, 357.4, 357.5, 357.6,
357.7, 357.8, 357.89, 357.9
AND
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337 (domiciliary),
99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350 (home visit),
Numerator Patients who were queried at least once annually about falls within the past 12 months.
Note: Participants are encouraged to use validated assessment. An example of this is

the multifactorial falls risk assessment, which is to be performed once a year as part of
an exam.31
6080F, Patient (or caregiver) queried about falls
6080F Patient (or caregiver) queried about falls
Denominator • Documentation of a medical reason for not querying the patient about falls
Exceptions (eg patient is cognitively impaired and unable to communicate, patient is non-
ambulatory)
• Documentation of a patient reason for not querying the patient about falls (eg
patient declines to answer the query about falls)

EVIDENCE CLASSIFICATIONS / RATING SCHEMES
1. American Academy of Neurology4,23-26

Classification of evidence for therapeutic articles
Class I: Prospective, randomized, controlled clinical trial with masked outcome assessment, in a representative population. The following
are required:
a) Primary outcome(s) is/are clearly defined.
b) Exclusion/inclusion criteria are clearly defined.
c) Adequate accounting for drop-outs and cross-overs with numbers sufficiently low to have minimal potential for bias.
d) Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical
adjustment for differences.
Class II: Prospective, matched, group cohort study in a representative population with masked outcome assessment that meets a-d above
OR a RCT in a representative population that lacks one criterion a–d.
Class III: All other controlled trials including well-defined natural history controls or patients serving as own controls in a representative
population, where outcome assessment is independently assessed or independently derived by objective outcome measurement (an
outcome measure that is unlikely to be affected by an observer’s [patient, treating physician, investigator] expectation or bias [eg, blood
tests, administrative outcome data]).
Class IV: Evidence from uncontrolled studies, case series, case reports, or expert opinion.
Classification of recommendations
A _ Established as effective, ineffective, or harmful for the given condition in the specified population. (Level A rating requires at least two
consistent
Class I studies.)
B _ Probably effective, ineffective, or harmful for the given condition in the specified population. (Level B rating requires at least one Class
I study or at least two consistent Class II studies.)
C _ Possibly effective, ineffective, or harmful for the given condition in the specified population. (Level C rating requires at least one Class
II study or two consistent Class III studies.)
U _ Data inadequate or conflicting given current knowledge, treatment is unproven.
2. American Diabetes Association evidence grading system for clinical practice recommendations27
Level of Evidence Description
A Clear evidence from well-conducted, generalizable, randomized controlled trials that are adequately powered,
including:
• Evidence from a well-conducted multicenter trial
• Evidence from a meta-analysis that incorporated quality ratings in the analysis
Compelling non-experimental evidence, i.e., “all or none” rule developed by Center for Evidence Based Medicine
at Oxford
Supportive evidence from well-conducted randomized controlled trials that are adequately powered, including:
• Evidence from a well-conducted trial at one or more institutions
• Evidence from a meta-analysis that incorporated quality ratings in the analysis
B Supportive evidence from well-conducted cohort studies
• Evidence from a well-conducted prospective cohort study or registry
• Evidence from a well-conducted meta-analysis of cohort studies
Supportive evidence from a well-conducted case-control study
C Supportive evidence from poorly controlled or uncontrolled studies
• Evidence from randomized clinical trials with one or more major or three or more minor methodological flaws
that could invalidate the results
• Evidence from observational studies with high potential for bias (such as case series with comparison to
historical controls)
• Evidence from case series or case reports
Conflicting evidence with the weight of evidence supporting the recommendation
E Expert consensus or clinical experience
3. United States Preventive Services Task Force (USPSTF) Ratings28

The Task Force grades its recommendations according to one of 5 classifications (A, B, C, D, I) reflecting the strength of evidence and
magnitude of net benefit (benefits minus harms):
A. The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the
service] improves important health outcomes and concludes that benefits substantially outweigh harms.

B. The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the
service] improves important health outcomes and concludes that benefits outweigh harms.
C. The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that
[the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general
recommendation.
D. The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence
that [the service] is ineffective or that harms outweigh benefits.
I. The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing the service. Evidence that [the
service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.
The USPSTF grades the quality of the overall evidence for a service on a 3-point scale (good, fair, poor):
Good: Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess
effects on health outcomes.
Fair: Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or
consistency of the individual studies, generalizability to routine practice, or indirect nature of the evidence on health outcomes.
Poor: Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in
their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.
4. National Quality Forum-National Voluntary Consensus Standards for the Treatment of Substance Use Conditions:
Evidence-Based Treatment Practices29
This project was conducted according to the NQF Consensus Development Process, and the 11 endorsed practices and their specifications
have legal status as national voluntary consensus standards for the treatment of substance use conditions. For each endorsed practice, the
target outcomes are identified, and additional specifications are provided for what a practice entails, for whom it is indicated, who performs
it, and the settings where it is provided. Consistent with the priorities established, these practices are applicable across a broad range of
populations (eg, adolescents and adults), settings (eg, primary care and substance use treatment settings), and providers (eg, counselors and
physicians).
5. Oxford Centre for Evidence-Based Medicine30

http://www.guideline.gov/disclaimer.aspx?redirect=http://www.cebm.net/index.aspx?o=1025
Rating scheme for strength of evidence
1a: Systematic review (SR) (with homogeneity) of randomized controlled trials
1b: Individual RCT (with narrow Confidence Interval)
1c: All or none (met when all patients died before the treatment because available, but now some survive on it; or when some patients died
before the treatment became available, but none now die on it)
2a: SR (with homogeneity) of cohort studies
2b: Individual cohort study (including low quality RCT; eg, <80% follow-up)
2c: "Outcomes" Research; Ecological studies
3a: SR (with homogeneity) of case-control studies
3b: Individual Case-Control Study
4: Case-series (and poor quality cohort and case-control studies)
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research, or "first principles"
Source: Oxford Centre for Evidence-based Medicine. Levels of evidence and grades of recommendation. Available at:
http://www.cebm.net/levels_of_evidence.asp
Rating Scheme for strength of recommendations
A: Consistent level 1 studies
B: Consistent level 2 or 3 studies or extrapolations from level 1 studies
C: Level 4 studies or extrapolations from level 2 or 3 studies
D: Level 5 evidence or troublingly inconsistent or inconclusive studies of any level
Source: Oxford Centre for Evidence-based Medicine. Levels of evidence and grades of recommendation. Available at:
http://www.cebm.net/levels_of_evidence.asp
6. American Geriatrics Society31

A standardized format based on an evidence rating system used by the U.S. Preventive Services Task Force was used to critically analyze
the literature and grade the evidence for this document.8 Based on overall quality of evidence and magnitude of benefit for each
intervention, the committee assigned a rating of A, B, C, or D to each recommendation (A5a strong recommendation that physicians
provide the intervention to eligible patients, B5a recommendation that clinicians provide this intervention to eligible patients, C5that no
recommendation for or against the routine provision of the intervention can be made, and D5that the panel recommends against routinely
providing the intervention to asymptomatic patients). If evidence was insufficient to come to a decision for or against the intervention, the
panel assigned a rating of I.
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Contact Information
For more information, please contact the American Academy of Neurology, [email protected]


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Distal Symmetric Polyneuropathy

Performance Measurement Set

Status: American Academy of Neurology Board of Directors Approved 07.30.2012

©2012. American Academy of Neurology. All Rights Reserved.

©2012 American Academy of Neurology. All rights reserved.

©2012. American Academy of Neurology. All Rights Reserved. 2

Desired Outcomes for Patients with DSP Pg 9

Purpose of Measurement Set Pg 10

Demonstrated Opportunity for Improvement Pg 11

Clinical Evidence Base Pg 11

Distal Symmetric Polyneuropathy Outcomes Pg 12

Intended Care Audience, Care Setting, and Patient Population Pg 12

Distal Symmetric Polyneuropathy Recommendations Pg 12

IOM Domains of Health Care Quality Pg 13

Other Potential Measures Pg 13

Potential for Future Measure Development in National Priority Partnership Areas Pg 13

Measure Implementation Initiative and Collaborative Pg 14

Technical Specifications Overview Pg 14

Testing and Implementation of the Measurement Set Pg 15

Measure #6: Querying about Falls for Patients with DSP Pg 32

Evidence Classification/Rating Schemes Pg 35

©2012. American Academy of Neurology. All Rights Reserved. 3

Quality Measurement and Reporting Subcommittee Facilitator

American Academy of Neurology American Academy of Physical

©2012. American Academy of Neurology. All Rights Reserved. 4

Reasons for Prioritizing Improvement in Distal Symmetric Polyneuropathy

©2012. American Academy of Neurology. All Rights Reserved. 5

Rigorous Clinical Evidence Base

Distal Symmetric Polyneuropathy Outcomes

Desired outcomes for DSP include:

Distal Symmetric Polyneuropathy Work Group Recommendations

Distal Symmetric Polyneuropathy Measures

Measures addressing appropriate diagnosis

Other Potential Measures

Existing Quality Improvement (QI) Initiative or Collaborative for Measure Implementation

Technical Specifications Overview

Testing and Implementation of the Measurement Set

©2012. American Academy of Neurology. All Rights Reserved. 8

Processes . . . that link to . . . Outcomes

Proposed Measure: Enhancing patient Reduce DSP

©2012. American Academy of Neurology. All Rights Reserved. 9

Mortality and Morbidity

Office Visits and Hospital Stays

Opportunity for Improvement

Clinical Evidence Base

Distal Symmetric Polyneuropathy Outcomes

Desired outcomes for DSP include:

Intended Audience, Care Setting, and Patient Population

Distal Symmetric Polyneuropathy Work Group Recommendations

Distal Symmetric Polyneuropathy

Institute Of Medicine Domains of Health Care Quality

Other Potential Measures

Existing Quality Improvement (QI) Initiative or Collaborative for Measure Implementation

Technical Specifications: Overview

Testing and Implementation of the Measurement Set

©2012. American Academy of Neurology. All Rights Reserved. 15

Distal symmetric polyneuropathy can be asymptomatic in its early stages. Asymptomatic

Peripheral neuropathy is estimated to affect more than 20 million Americans.3 1 in 3 patients

IOM Domains • Safe

©2012. American Academy of Neurology. All Rights Reserved. 17