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Functional Status Assessment for Total Hip Replacement

CMS Measure ID
CMS56v8
Version
8
NQF Number
Not Applicable
Measure Description

Percentage of patients 18 years of age and older who received an elective primary total hip arthroplasty (THA) and completed a functional status assessment within 90 days prior to the surgery and in the 270-365 days after the surgery

Initial Population

Patients 19 years of age and older who had a primary total hip arthroplasty (THA) in the year prior to the measurement period and who had an outpatient encounter during the measurement period

Denominator Statement
Denominator Exclusions

Patients with two or more fractures indicating trauma at the time of the total hip arthroplasty or patients with severe cognitive impairment that overlaps the measurement period.

Numerator Statement

Patients with patient-reported functional status assessment results (i.e., VR-12, PROMIS-10-Global Health, Hip Disability and Osteoarthritis Outcome Score [HOOS], HOOS Jr.) in the 90 days prior to or on the day of the primary THA procedure, and in the 270 - 365 days after the THA procedure

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Previous Version
Measure Scoring
Measure Type
Improvement Notation

A higher score indicates better quality

Guidance

A functional status assessment (FSA) is based on administration of a validated instrument to eligible patients that asks patients to answer questions related to various domains including: pain, physical function, emotional well-being, health-related quality of life, symptom acuity.

The same FSA instrument must be used for the initial and follow-up assessment.

Quality ID
376
Meaningful Measure

Specifications

Attachment Size
CMS56v8.html 68.21 KB
CMS56v8.zip 82.24 KB
CMS56v8-TRN.xlsx 22.39 KB

Release Notes

 

Header

  • Updated eCQM version number.

    Measure Section: eCQM Version number

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated clinical recommendation statement.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references to align with American Psychological Association (APA) style.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated guidance statement to correct grammatical errors for clarity and to improve alignment across measures.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated multiple sections in header by defining acronyms and correcting grammatical errors for clarity.

    Measure Section: Multiple Sections

    Source of Change: ONC Project Tracking System (JIRA): CQM-3114

  • Updated parenthetical citations to align with American Psychological Association (APA) style.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

 

Logic

  • Added logic to capture functional status assessments using the same tool before and after the procedure to improve alignment with measure intent.

    Measure Section: Numerator

    Source of Change: ONC Project Tracking System (JIRA): CQM-3114

  • Replaced Numerator definitions 'Total Hip Arthroplasty with Initial Assessment' and 'Hip Assessment 270 to 365 Days after Total Hip Arthroplasty Procedure' with 'Assessed Initial and Followup HOOS with THA', 'Assessed Initial and Followup HOOSJr with THA', 'Assessed Initial and Followup PROMIS10 with THA', 'Assessed Initial and Followup VR12 Oblique with THA', and 'Assessed Initial and Followup VR12 Orthogonal with THA' to capture functional status assessments using the same tool before and after the procedure to improve alignment with measure intent.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-3114

  • Updated the names of Clinical Quality Language (CQL) definitions, functions, and/or aliases for clarification and to align with CQL Style Guide.

    Measure Section: Definitions and Functions

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 3 (CQL 1.3).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated definitions and functions in the Measure Authoring Tool (MAT) Global Common Functions Library to align with standards changes, Clinical Quality Language (CQL) Style Guide, and to include two new functions related to calculating hospital stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Hospice Library (Hospice-2.0.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-4.0.000).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

 

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Replaced value set VR12 Mental Component T Score (2.16.840.1.113883.3.464.1003.118.12.1177) with direct reference codes (LOINC codes (72026-8, 72028-4)).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set VR12 Physical Component T Score (2.16.840.1.113883.3.464.1003.118.12.1176) with direct reference codes (LOINC codes (72025-0, 72027-6).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set PROMIS 10 Global Mental Health Score (2.16.840.1.113883.3.464.1003.118.12.1138) with direct reference code (LOINC code (71969-0)).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Replaced value set PROMIS 10 Global Physical Health Score (2.16.840.1.113883.3.464.1003.118.12.1139) with direct reference code (LOINC Code (71971-6)).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Primary THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006): Deleted 1 SNOMED CT code (55423004).

    Measure Section: Terminology

    Source of Change: Annual Update

  • Direct reference code for Birth date (LOINC Code (21112-8)) now displayed in Human Readable.

    Measure Section: Terminology

    Source of Change: Annual Update

  • ​Removed code system versions from direct reference codes. Please refer to Appendix A of the Electronic Clinical Quality Measure Logic and Implementation Guidance document for a list of code system versions used in the eCQM specifications for 2020 reporting/performance.

    Measure Section: Terminology

    Source of Change: Standards Update

  • Standardized purpose statement language in value sets across eCQMs. Value set purpose statements are visible in the Value Set Authority Center (VSAC) as well as the downloadable eCQM value set files.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jul 22, 2019