eCQM Title | # Functional Status Assessment for Total Hip Replacement
eCQM Identifier (Measure Authoring Tool) | 56 | eCQM Version Number | 11.0.000
NQF Number | Not Applicable | GUID | 2f291003-3f2f-48af-bef9-e5aacb95ac3e
Measurement Period | January 1, 20XX through December 31, 20XX
Measure Steward | Centers for Medicare & Medicaid Services (CMS)
Measure Developer | National Committee for Quality Assurance
Endorsed By | None
Description |
    Percentage of patients 19 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
Copyright |
    This Physician Performance Measure (Measure) and related data specifications are owned and stewarded by the Centers for Medicare & Medicaid Services (CMS). CMS contracted (Contract HHSP23320095627WC; HHSP23337008T) with the National Committee for Quality Assurance (NCQA) to develop this electronic measure. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications.

    Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any third party codes contained in the specifications.

    CPT(R) contained in the Measure specifications is copyright 2004-2021 American Medical Association. LOINC(R) copyright 2004-2021 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2021 International Health Terminology Standards Development Organisation. ICD-10 copyright 2021 World Health Organization. All Rights Reserved.
Disclaimer |
    The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.

    Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].
Measure Scoring | Proportion
Measure Type | Process
Stratification |
    None
Risk Adjustment |
    None
Rate Aggregation |
    None
Rationale |
    Total hip arthroplasties (THAs) are common surgical procedures that address hip pain and functional impairment, primarily caused by osteoarthritis. Although THA is an effective procedure for addressing osteoarthritis for many patients, some people, particularly those with more severe preoperative pain and impairment, do not experience the improvements in pain, function, and quality of life expected from the procedure (Beswick et al., 2012; Fortin et al., 1999; Tilbury et al., 2016). In 2010, providers performed 326,100 THAs, with 95 percent of them in patients age 45 and older (Wolford, Palso, & Bercovitz, 2015). Although THAs were introduced as a procedure for older adults, the percentage of patients age 55 to 64 (29 percent) who had a THA in 2010 exceeded the percentage of patients age 75 and older (26 percent) who had a THA (Wolford, Palso, & Bercovitz, 2015). Kurtz et al. (2009) projected that patients younger than 65 would account for 52 percent of THAs by 2030. This growth in hip surgeries for patients younger than 65 is significant because these patients often require more expensive joint arthroplasties that will better withstand the wear caused by physical activity (Bozic et al., 2006).

    This measure evaluates whether patients complete a patient-reported functional status assessment (FSA) before and after a THA. Measuring functional status for patients undergoing THA permits longitudinal assessment - from the patient's perspective - of the impact of surgical intervention on pain, physical function, as well as health-related quality of life (Rothrock, 2010).
Clinical Recommendation Statement |
    While there is no clinical guideline recommending that clinicians assess patients who are undergoing total hip replacements using patient-reported outcomes of function and pain, several clinical specialty societies support the use of a general health questionnaire and a disease-specific questionnaire for these patients. In particular, they recommend the Veterans RAND 12-item health survey (VR-12) or the Patient-Reported Outcomes Measurement Information System [PROMIS]-10-Global as the general health questionnaire and the Hip Disability and Osteoarthritis Outcome Score [HOOS], Jr. as the disease-specific questionnaire (American Association of Orthopaedic Surgeons, the American Joint Replacement Registry, The Hip Society, The Knee Society, & the American Association of Hip and Knee Surgeons, 2015).
Improvement Notation |
    A higher score indicates better quality
Reference |
    Reference Type: CITATION
    Reference Text: 'American Association of Orthopaedic Surgeons, The American Joint Replacement Registry, The Hip Society, The Knee Society, & the American Association of Hip and Knee Surgeons. (2015). Patient-reported outcomes summit for total joint arthroplasty report. Retrieved from http://www.aahks.org/wp-content/uploads/2018/08/comment-letter-pro-summit-09082015.pdf'
Reference |
    Reference Type: CITATION
    Reference Text: 'Beswick, A. D., Wylde, V., Gooberman-Hill, R., et al. (2012). What Proportion of Patients Report Long-Term Pain after Total Hip or Knee Replacement for Osteoarthritis? A Systematic Review of Prospective Studies in Unselected Patients. British Medical Journal Open, 2(1), 1-12.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Bozic, K. J., Morsehed, S., Silverstein, M. D., et al. (2006). Use of Cost-Effectiveness Analysis to Evaluate New Technologies in Orthopaedics: The Case of Alternative Bearing Surfaces in Total Hip Arthroplasty. Journal of Bone and Joint Surgery, American Volume, 88(4), 706-714.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Fortin, P. R., Clarke, A. E., Joseph, L., et al. (1999). Outcomes of Total Hip and Knee Replacement Preoperative Functional Status Predicts Outcomes at Six Months After Surgery. American College of Rheumatology, 42(8), 1722-1728.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Kurtz, S. M., Lau, E., Ong, K., et al. (2009). Future Young Patient Demand for Primary and Revision Joint Arthroplasty: National projections from 2010 to 2030. Clinical Orthopaedics and Related Research, 467(10), 2606-2612.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Rothrock, N. E., Hays, R. D., Spritzer, K., et al. (2010). Relative to the General U.S. Population, Chronic Diseases are Associated with Poorer Health-Related Quality of Life as Measured by the Patient-Reported Outcomes Measurement Information System (PROMIS). Journal of Clinical Epidemiology, 63(11), 1195-1204.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Tilbury, C., Haanstra, T. M., Leichtenberg, C. S., et al. (2016). Unfulfilled Expectations after Total Hip and Knee Arthroplasty Surgery: There is a Need for Better Preoperative Patient Information and Education. Journal of Arthroplasty, 31(10), 2136-2145.'
Reference |
    Reference Type: CITATION
    Reference Text: 'Wolford, M. L., Palso, K., & Bercovitz, A. (2015, February). Hospitalization for Total Hip Replacement Among Inpatients Aged 45 and Over: United States, 2000-2010. NCHS Data Brief No. 186. Hyattsville, MD: National Center for Health Statistics.'
Definition |
    None
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 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.
Transmission Format |
    TBD
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 |
    Equals Initial Population
Denominator Exclusions |
    Exclude patients with two or more fractures indicating trauma in the 24 hours before or at the start of the total hip arthroplasty or patients with severe cognitive impairment that starts before or in any part of the measurement period.

    Exclude patients who are in hospice care for any part of the measurement period.
Numerator |
    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, 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
Supplemental Data Elements |
    For every patient evaluated by this measure also identify payer, race, ethnicity and sex

## Table of Contents

- Population Criteria
- Definitions
- Functions
- Terminology
- Data Criteria (QDM Data Elements)
- Supplemental Data Elements
- Risk Adjustment Variables

### Population Criteria

- - Initial Population

    - -     "Has Qualifying Encounter"
              and exists ( "Total Hip Arthroplasty Procedure" )
              and AgeInYearsAt(date from start of "Measurement Period")>= 19

- - Denominator

    - -     "Initial Population"

- - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or "Has Total Hip Arthroplasty with 2 or More Lower Body Fractures"
              or "Has Dementia Diagnosis"

- - Numerator

    - -     ( "Has THA with Initial and Follow Up HOOS Assessments" )
              or ( "Has THA with Initial and Follow Up HOOSJr Assessments" )
              or ( "Has THA with Initial and Follow Up PROMIS10 Assessments" )
              or ( "Has THA with Initial and Follow Up VR12 Oblique Assessments" )
              or ( "Has THA with Initial and Follow Up VR12 Orthogonal Assessments" )

- - Numerator Exclusions

    - -     None

- - Denominator Exceptions

    - -     None

- - Stratification

    - -     None

### Definitions

- - Denominator

    - -     "Initial Population"

  - Denominator Exclusions

    - -     Hospice."Has Hospice Services"
              or "Has Total Hip Arthroplasty with 2 or More Lower Body Fractures"
              or "Has Dementia Diagnosis"

  - Has Dementia Diagnosis

    - -     exists ( ["Diagnosis": "Severe dementia (disorder)"] Dementia
                where Dementia.prevalencePeriod overlaps "Measurement Period"
            )

  - Has Qualifying Encounter

    - -     exists ( ( ["Encounter, Performed": "Outpatient Consultation"]
                union ["Encounter, Performed": "Office Visit"]
                union ["Encounter, Performed": "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure"]
                union ["Encounter, Performed": "Telephone Visits"]
                union ["Encounter, Performed": "Online Assessments"] ) ValidEncounters
                where ValidEncounters.relevantPeriod during day of "Measurement Period"
            )

  - Has THA with Initial and Follow Up HOOS Assessments

    - -     exists ( ( "Total Hip Arthroplasty Procedure" THAProcedure
                return Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) ) TotalHip
                with "Time HOOS Total Assessment Completed" InitialHipAssessmentHOOS
                  such that TotalHip starts 90 days or less on or after InitialHipAssessmentHOOS
                with "Time HOOS Total Assessment Completed" FollowUpHipAssessmentHOOS
                  such that FollowUpHipAssessmentHOOS during day of Interval[
                  end of TotalHip + 270 days,
                  end of TotalHip + 365 days]
            )

  - Has THA with Initial and Follow Up HOOSJr Assessments

    - -     exists ( ( "Total Hip Arthroplasty Procedure" THAProcedure
                return Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) ) TotalHip
                with "Time HOOSJr Total Assessment Completed" InitialHipAssessment
                  such that TotalHip starts 90 days or less on or after InitialHipAssessment
                with "Time HOOSJr Total Assessment Completed" FollowUpHipAssessment
                  such that FollowUpHipAssessment during day of Interval[
                  end of TotalHip + 270 days,
                  end of TotalHip + 365 days]
            )

  - Has THA with Initial and Follow Up PROMIS10 Assessments

    - -     exists ( ( "Total Hip Arthroplasty Procedure" THAProcedure
                return Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) ) TotalHip
                with "Time PROMIS10 Total Assessment Completed" InitialHipAssessmentPROMIS10
                  such that TotalHip starts 90 days or less on or after InitialHipAssessmentPROMIS10
                with "Time PROMIS10 Total Assessment Completed" FollowUpHipAssessmentPROMIS10
                  such that FollowUpHipAssessmentPROMIS10 during day of Interval[
                  end of TotalHip + 270 days,
                  end of TotalHip + 365 days]
            )

  - Has THA with Initial and Follow Up VR12 Oblique Assessments

    - -     exists ( ( "Total Hip Arthroplasty Procedure" THAProcedure
                return Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) ) TotalHip
                with "Time VR12 Oblique Total Assessment Completed" InitialHipAssessmentOblique
                  such that TotalHip starts 90 days or less on or after InitialHipAssessmentOblique
                with "Time VR12 Oblique Total Assessment Completed" FollowUpHipAssessmentOblique
                  such that FollowUpHipAssessmentOblique during day of Interval[
                  end of TotalHip + 270 days,
                  end of TotalHip + 365 days]
            )

  - Has THA with Initial and Follow Up VR12 Orthogonal Assessments

    - -     exists ( ( "Total Hip Arthroplasty Procedure" THAProcedure
                return Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) ) TotalHip
                with "Time VR12 Orthogonal Total Assessment Completed" InitialHipAssessmentOrthogonal
                  such that TotalHip starts 90 days or less on or after InitialHipAssessmentOrthogonal
                with "Time VR12 Orthogonal Total Assessment Completed" FollowUpHipAssessmentOrthogonal
                  such that FollowUpHipAssessmentOrthogonal during day of Interval[
                  end of TotalHip + 270 days,
                  end of TotalHip + 365 days]
            )

  - Has Total Hip Arthroplasty with 2 or More Lower Body Fractures

    - -     exists ( "Total Hip Arthroplasty Procedure" THAProcedure
                where Count(["Diagnosis": "Lower Body Fracture"] LowerBodyFracture
                    where LowerBodyFracture.prevalencePeriod starts 24 hours or less on or before start of Global."NormalizeInterval"(THAProcedure.relevantDatetime, THAProcedure.relevantPeriod)
                )>= 2
            )

  - Hospice.Has Hospice Services

    - -     exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
                where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                    or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
                )
                  and InpatientEncounter.relevantPeriod ends during day of "Measurement Period"
            )
              or exists ( ["Encounter, Performed": "Hospice Encounter"] HospiceEncounter
                  where HospiceEncounter.relevantPeriod overlaps "Measurement Period"
              )
              or exists ( ["Assessment, Performed": "Hospice care [Minimum Data Set]"] HospiceAssessment
                  where HospiceAssessment.result ~ "Yes (qualifier value)"
                    and Global."NormalizeInterval" ( HospiceAssessment.relevantDatetime, HospiceAssessment.relevantPeriod ) overlaps "Measurement Period"
              )
              or exists ( ["Intervention, Order": "Hospice Care Ambulatory"] HospiceOrder
                  where HospiceOrder.authorDatetime during day of "Measurement Period"
              )
              or exists ( ["Intervention, Performed": "Hospice Care Ambulatory"] HospicePerformed
                  where Global."NormalizeInterval" ( HospicePerformed.relevantDatetime, HospicePerformed.relevantPeriod ) overlaps "Measurement Period"
              )

  - Initial Population

    - -     "Has Qualifying Encounter"
              and exists ( "Total Hip Arthroplasty Procedure" )
              and AgeInYearsAt(date from start of "Measurement Period")>= 19

  - Numerator

    - -     ( "Has THA with Initial and Follow Up HOOS Assessments" )
              or ( "Has THA with Initial and Follow Up HOOSJr Assessments" )
              or ( "Has THA with Initial and Follow Up PROMIS10 Assessments" )
              or ( "Has THA with Initial and Follow Up VR12 Oblique Assessments" )
              or ( "Has THA with Initial and Follow Up VR12 Orthogonal Assessments" )

  - SDE Ethnicity

    - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

  - SDE Payer

    - -     ["Patient Characteristic Payer": "Payer"]

  - SDE Race

    - -     ["Patient Characteristic Race": "Race"]

  - SDE Sex

    - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

  - Time HOOS Total Assessment Completed

    - -     from
              ["Assessment, Performed": "Quality of life score [HOOS]"] HOOSLifeQuality,
              ["Assessment, Performed": "Sport-recreation score [HOOS]"] HOOSSport,
              ["Assessment, Performed": "Activities of daily living score [HOOS]"] HOOSActivityScore,
              ["Assessment, Performed": "Symptoms score [HOOS]"] HOOSSymptoms,
              ["Assessment, Performed": "Pain score [HOOS]"] HOOSPain
              let HOOSLifeQualityTime: start of Global."NormalizeInterval" ( HOOSLifeQuality.relevantDatetime, HOOSLifeQuality.relevantPeriod ),
              HOOSSportTime: start of Global."NormalizeInterval" ( HOOSSport.relevantDatetime, HOOSSport.relevantPeriod ),
              HOOSActivityScoreTime: start of Global."NormalizeInterval" ( HOOSActivityScore.relevantDatetime, HOOSActivityScore.relevantPeriod ),
              HOOSSymptomsTime: start of Global."NormalizeInterval" ( HOOSSymptoms.relevantDatetime, HOOSSymptoms.relevantPeriod ),
              HOOSPainTime: start of Global."NormalizeInterval" ( HOOSPain.relevantDatetime, HOOSPain.relevantPeriod )
              where HOOSLifeQualityTime same day as HOOSSportTime
                and HOOSSport.result is not null
                and HOOSLifeQualityTime same day as HOOSActivityScoreTime
                and HOOSActivityScore.result is not null
                and HOOSLifeQualityTime same day as HOOSSymptomsTime
                and HOOSSymptoms.result is not null
                and HOOSLifeQualityTime same day as HOOSPainTime
                and HOOSPain.result is not null
                and HOOSLifeQuality.result is not null
              return Max({ HOOSLifeQualityTime, HOOSSportTime, HOOSActivityScoreTime, HOOSSymptomsTime, HOOSPainTime })

  - Time HOOSJr Total Assessment Completed

    - -     ( ["Assessment, Performed": "Total interval score [HOOSJR]"] HOOSJr
              where HOOSJr.result is not null ) DocumentedHOOSJr
              return start of Global."NormalizeInterval" ( DocumentedHOOSJr.relevantDatetime, DocumentedHOOSJr.relevantPeriod )

  - Time PROMIS10 Total Assessment Completed

    - -     from
              ["Assessment, Performed": "PROMIS-10 Global Mental Health (GMH) score T-score"] PROMIS10MentalScore,
              ["Assessment, Performed": "PROMIS-10 Global Physical Health (GPH) score T-score"] PROMIS10PhysicalScore
              let PROMIS10MentalScoreTime: start of Global."NormalizeInterval" ( PROMIS10MentalScore.relevantDatetime, PROMIS10MentalScore.relevantPeriod ),
              PROMIS10PhysicalScoreTime: start of Global."NormalizeInterval" ( PROMIS10PhysicalScore.relevantDatetime, PROMIS10PhysicalScore.relevantPeriod )
              where PROMIS10MentalScoreTime same day as PROMIS10PhysicalScoreTime
                and PROMIS10PhysicalScore.result is not null
                and PROMIS10MentalScore.result is not null
              return Max({ PROMIS10MentalScoreTime, PROMIS10PhysicalScoreTime })

  - Time VR12 Oblique Total Assessment Completed

    - -     from
              ["Assessment, Performed": "VR-12 Mental component summary (MCS) score - oblique method T-score"] VR12MentalAssessment,
              ["Assessment, Performed": "VR-12 Physical component summary (PCS) score - oblique method T-score"] VR12PhysicalAssessment
              let VR12MentalAssessmentTime: start of Global."NormalizeInterval" ( VR12MentalAssessment.relevantDatetime, VR12MentalAssessment.relevantPeriod ),
              VR12PhysicalAssessmentTime: start of Global."NormalizeInterval" ( VR12PhysicalAssessment.relevantDatetime, VR12PhysicalAssessment.relevantPeriod )
              where VR12MentalAssessmentTime same day as VR12PhysicalAssessmentTime
                and VR12MentalAssessment.result is not null
                and VR12PhysicalAssessment.result is not null
              return Max({ VR12MentalAssessmentTime, VR12PhysicalAssessmentTime })

  - Time VR12 Orthogonal Total Assessment Completed

    - -     from
              ["Assessment, Performed": "VR-12 Mental component summary (MCS) score - orthogonal method T-score"] VR12MentalAssessment,
              ["Assessment, Performed": "VR-12 Physical component summary (PCS) score - orthogonal method T-score"] VR12PhysicalAssessment
              let VR12MentalAssessmentTime: start of Global."NormalizeInterval" ( VR12MentalAssessment.relevantDatetime, VR12MentalAssessment.relevantPeriod ),
              VR12PhysicalAssessmentTime: start of Global."NormalizeInterval" ( VR12PhysicalAssessment.relevantDatetime, VR12PhysicalAssessment.relevantPeriod )
              where VR12MentalAssessmentTime same day as VR12PhysicalAssessmentTime
                and VR12MentalAssessment.result is not null
                and VR12PhysicalAssessment.result is not null
              return Max({ VR12MentalAssessmentTime, VR12PhysicalAssessmentTime })

  - Total Hip Arthroplasty Procedure

    - -     ["Procedure, Performed": "Primary THA Procedure"] THAProcedure
              where Global."NormalizeInterval" ( THAProcedure.relevantDatetime, THAProcedure.relevantPeriod ) starts 12 months or less on or before start of "Measurement Period"

### Functions

- - Global.NormalizeInterval(pointInTime DateTime, period Interval<DateTime>)

    - -     if pointInTime is not null then Interval[pointInTime, pointInTime]
              else if period is not null then period
              else null as Interval<DateTime>

### Terminology

- code "Activities of daily living score [HOOS]" ("LOINC Code (72095-3)")
- code "Discharge to healthcare facility for hospice care (procedure)" ("SNOMEDCT Code (428371000124100)")
- code "Discharge to home for hospice care (procedure)" ("SNOMEDCT Code (428361000124107)")
- code "Hospice care [Minimum Data Set]" ("LOINC Code (45755-6)")
- code "Pain score [HOOS]" ("LOINC Code (72097-9)")
- code "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure" ("CPT Code (99024)")
- code "PROMIS-10 Global Mental Health (GMH) score T-score" ("LOINC Code (71969-0)")
- code "PROMIS-10 Global Physical Health (GPH) score T-score" ("LOINC Code (71971-6)")
- code "Quality of life score [HOOS]" ("LOINC Code (72093-8)")
- code "Severe dementia (disorder)" ("SNOMEDCT Code (428351000124105)")
- code "Sport-recreation score [HOOS]" ("LOINC Code (72094-6)")
- code "Symptoms score [HOOS]" ("LOINC Code (72096-1)")
- code "Total interval score [HOOSJR]" ("LOINC Code (82323-7)")
- code "VR-12 Mental component summary (MCS) score - oblique method T-score" ("LOINC Code (72026-8)")
- code "VR-12 Mental component summary (MCS) score - orthogonal method T-score" ("LOINC Code (72028-4)")
- code "VR-12 Physical component summary (PCS) score - oblique method T-score" ("LOINC Code (72025-0)")
- code "VR-12 Physical component summary (PCS) score - orthogonal method T-score" ("LOINC Code (72027-6)")
- code "Yes (qualifier value)" ("SNOMEDCT Code (373066001)")
- valueset "Encounter Inpatient" (2.16.840.1.113883.3.666.5.307)
- valueset "Ethnicity" (2.16.840.1.114222.4.11.837)
- valueset "Hospice Care Ambulatory" (2.16.840.1.113883.3.526.3.1584)
- valueset "Hospice Encounter" (2.16.840.1.113883.3.464.1003.1003)
- valueset "Lower Body Fracture" (2.16.840.1.113883.3.464.1003.113.12.1037)
- valueset "Office Visit" (2.16.840.1.113883.3.464.1003.101.12.1001)
- valueset "ONC Administrative Sex" (2.16.840.1.113762.1.4.1)
- valueset "Online Assessments" (2.16.840.1.113883.3.464.1003.101.12.1089)
- valueset "Outpatient Consultation" (2.16.840.1.113883.3.464.1003.101.12.1008)
- valueset "Payer" (2.16.840.1.114222.4.11.3591)
- valueset "Primary THA Procedure" (2.16.840.1.113883.3.464.1003.198.12.1006)
- valueset "Race" (2.16.840.1.114222.4.11.836)
- valueset "Telephone Visits" (2.16.840.1.113883.3.464.1003.101.12.1080)

### Data Criteria (QDM Data Elements)

- "Assessment, Performed: Activities of daily living score [HOOS]" using "Activities of daily living score [HOOS] (LOINC Code 72095-3)"
- "Assessment, Performed: Hospice care [Minimum Data Set]" using "Hospice care [Minimum Data Set] (LOINC Code 45755-6)"
- "Assessment, Performed: Pain score [HOOS]" using "Pain score [HOOS] (LOINC Code 72097-9)"
- "Assessment, Performed: PROMIS-10 Global Mental Health (GMH) score T-score" using "PROMIS-10 Global Mental Health (GMH) score T-score (LOINC Code 71969-0)"
- "Assessment, Performed: PROMIS-10 Global Physical Health (GPH) score T-score" using "PROMIS-10 Global Physical Health (GPH) score T-score (LOINC Code 71971-6)"
- "Assessment, Performed: Quality of life score [HOOS]" using "Quality of life score [HOOS] (LOINC Code 72093-8)"
- "Assessment, Performed: Sport-recreation score [HOOS]" using "Sport-recreation score [HOOS] (LOINC Code 72094-6)"
- "Assessment, Performed: Symptoms score [HOOS]" using "Symptoms score [HOOS] (LOINC Code 72096-1)"
- "Assessment, Performed: Total interval score [HOOSJR]" using "Total interval score [HOOSJR] (LOINC Code 82323-7)"
- "Assessment, Performed: VR-12 Mental component summary (MCS) score - oblique method T-score" using "VR-12 Mental component summary (MCS) score - oblique method T-score (LOINC Code 72026-8)"
- "Assessment, Performed: VR-12 Mental component summary (MCS) score - orthogonal method T-score" using "VR-12 Mental component summary (MCS) score - orthogonal method T-score (LOINC Code 72028-4)"
- "Assessment, Performed: VR-12 Physical component summary (PCS) score - oblique method T-score" using "VR-12 Physical component summary (PCS) score - oblique method T-score (LOINC Code 72025-0)"
- "Assessment, Performed: VR-12 Physical component summary (PCS) score - orthogonal method T-score" using "VR-12 Physical component summary (PCS) score - orthogonal method T-score (LOINC Code 72027-6)"
- "Diagnosis: Lower Body Fracture" using "Lower Body Fracture (2.16.840.1.113883.3.464.1003.113.12.1037)"
- "Diagnosis: Severe dementia (disorder)" using "Severe dementia (disorder) (SNOMEDCT Code 428351000124105)"
- "Encounter, Performed: Encounter Inpatient" using "Encounter Inpatient (2.16.840.1.113883.3.666.5.307)"
- "Encounter, Performed: Hospice Encounter" using "Hospice Encounter (2.16.840.1.113883.3.464.1003.1003)"
- "Encounter, Performed: Office Visit" using "Office Visit (2.16.840.1.113883.3.464.1003.101.12.1001)"
- "Encounter, Performed: Online Assessments" using "Online Assessments (2.16.840.1.113883.3.464.1003.101.12.1089)"
- "Encounter, Performed: Outpatient Consultation" using "Outpatient Consultation (2.16.840.1.113883.3.464.1003.101.12.1008)"
- "Encounter, Performed: Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure" using "Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure (CPT Code 99024)"
- "Encounter, Performed: Telephone Visits" using "Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080)"
- "Intervention, Order: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Intervention, Performed: Hospice Care Ambulatory" using "Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584)"
- "Patient Characteristic Ethnicity: Ethnicity" using "Ethnicity (2.16.840.1.114222.4.11.837)"
- "Patient Characteristic Payer: Payer" using "Payer (2.16.840.1.114222.4.11.3591)"
- "Patient Characteristic Race: Race" using "Race (2.16.840.1.114222.4.11.836)"
- "Patient Characteristic Sex: ONC Administrative Sex" using "ONC Administrative Sex (2.16.840.1.113762.1.4.1)"
- "Procedure, Performed: Primary THA Procedure" using "Primary THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006)"

### Supplemental Data Elements

- SDE Ethnicity

  - -     ["Patient Characteristic Ethnicity": "Ethnicity"]

- SDE Payer

  - -     ["Patient Characteristic Payer": "Payer"]

- SDE Race

  - -     ["Patient Characteristic Race": "Race"]

- SDE Sex

  - -     ["Patient Characteristic Sex": "ONC Administrative Sex"]

### Risk Adjustment Variables

- None

Measure Set |
    Not Applicable