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Functional Status Assessment for Total Knee Replacement

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eCQMs for 2021 Performance Period

CMS2v10
CMS22v9
CMS50v9
CMS56v9
CMS66v9
CMS68v10
CMS69v9
CMS74v10
CMS75v9
CMS90v10
CMS117v9
CMS122v9
CMS124v9
CMS125v9
CMS127v9
CMS128v9
CMS129v10
CMS130v9
CMS131v9
CMS133v9
CMS134v9
CMS135v9
CMS136v10
CMS137v9
CMS138v9
CMS139v9
CMS142v9
CMS143v9
CMS144v9
CMS145v9
CMS146v9
CMS147v10
CMS149v9
CMS153v9
CMS154v9
CMS155v9
CMS156v9
CMS157v9
CMS159v9
CMS161v9
CMS165v9
CMS177v9
CMS249v3
CMS347v4
CMS349v3
CMS645v4
CMS771v2

General eCQM Information

CMS Measure ID CMS66v9
NQF Number Not Applicable
Measure Description

Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) 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 knee arthroplasty (TKA) in the year prior to the measurement period and who had an outpatient encounter during the measurement period
Denominator Statement

Equals Initial Population
Denominator Exclusions

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

Exclude patients whose hospice care overlaps the measurement period.
Numerator Statement

Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12], Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA procedure
Numerator Exclusions

Not Applicable
Denominator Exceptions

None
Measure Steward Centers for Medicare & Medicaid Services (CMS)
Domain Person and Caregiver-Centered Experience and Outcomes
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

A higher score indicates better quality
Guidance

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

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.
Quality ID 375
Meaningful Measure Functional Outcomes
Telehealth Eligible Yes
Previous Version
CMS66v8
Specifications
Attachment Size
CMS66v9.html 71.71 KB
CMS66v9.zip 84.5 KB
CMS66v9-TRN.xlsx 22.03 KB

Data Element Repository

Release Notes

CMS66v9-TRN.xlsx

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale to change 'elderly' to 'older adults' to use a more neutral description.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • ​​Updated clinical recommendation statement to align with the most recent clinical practice guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated clinical recommendation statement to define Veterans RAND 12-Item Health Survey (VR-12), Patient-Reported Outcomes Measurement Information System (PROMIS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) assessment types.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated Guidance to use the same functional status assessment (FSA) instrument for the initial and follow-up assessments to promote harmonization between CMS56, CMS66 and CMS90.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • Standardized the use of 'Follow Up' in definition names to promote harmonization between CMS56, CMS66 and CMS90.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added the 'Max' operator to ensure the time of the last assessment component is used in relation to other events (applicable for all assessment types) and improve alignment with measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Standardized the use of 'Follow Up' in definition names to promote harmonization between CMS56, CMS66 and CMS90.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated timing logic for the follow-up assessment to use 'in Interval' to simplify logic and promote harmonization between measures.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Clinical Quality Language (CQL) Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    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.

  • Value set Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008): Deleted 1 SNOMED CT code (17436001) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Primary TKA Procedure (2.16.840.1.113883.3.464.1003.198.12.1007): Deleted 1 SNOMED CT code (430698003) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Value set Fracture - Lower Body (2.16.840.1.113883.3.464.1003.113.12.1037): Deleted 1 SNOMED CT code (208540000) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Dec 18, 2020