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Functional Status Assessment for Total Hip Replacement

Measure Information 2021 Performance Period
CMS eCQM ID CMS56v9
NQF Number Not Applicable
MIPS Quality ID 376
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

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

Equals Initial Population

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.

Exclude patients whose hospice care overlaps the measurement period.

Denominator Exceptions

None

Steward Centers for Medicare & Medicaid Services (CMS)
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.

Telehealth Eligible Yes
Next Version
Previous Version No Version Available

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Filter Measure By
Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title Functional Status Assessment for Total Hip Replacement Functional Status Assessment for Total Hip Replacement Functional Status Assessment for Total Hip Replacement Functional Status Assessment for Total Hip Replacement
CMS eCQM ID CMS56v9 CMS56v10 CMS56v11 CMS56v12
NQF Number Not Applicable Not Applicable Not Applicable Not Applicable
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

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

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

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 300 - 425 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

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

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

Patients 19 years of age and older who had a primary THA between November two years prior to the measurement period and October of the year prior to measurement period; and who had an outpatient encounter between November of the year prior to the measurement period and the end of the measurement period

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Equals Initial Population

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. Exclude patients whose hospice care overlaps the measurement period. Exclude patients with two or more fractures indicating trauma at the time 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. 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. Exclude patients who are in hospice care for any part of the measurement period.Exclude patients with severe cognitive impairment that starts before or in any part of the measurement period.Exclude patients with one or more specific lower body fractures indicating trauma in the 24 hours before or at the start of the total hip arthroplasty.Exclude patients with a partial hip arthroplasty procedure on the day of the total hip arthroplasty.Exclude patients with a revision hip arthroplasty procedure, an implanted device/prosthesis removal procedure or a resurfacing/supplement procedure on the day of the total hip arthroplasty.Exclude patients with a malignant neoplasm of the pelvis, sacrum, coccyx, lower limbs, or bone/bone marrow or a disseminated malignant neoplasm on the day of the total hip arthroplasty.Exclude patients with a mechanical complication on the day of the total hip arthroplasty.Exclude patients with a second total hip arthroplasty procedure 1 year before or after the original total hip arthroplasty procedure.Exclude patients who die on the day of the total hip arthroplasty procedure or in the 300 days after.
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

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

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

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 300 - 425 days after the THA procedure

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

None

None

None

None

Measure Steward Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS)
Measure Scoring Proportion measure Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure Process measure
Improvement Notation

A higher score indicates better quality

A higher score indicates better quality

A higher score indicates better quality

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.

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.

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 QDM page for more information on the QDM.

The same 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 QDM page for more information on the QDM.

MIPS Quality ID 376 376 376 376
Telehealth Eligible Yes Yes Yes Yes
Next Version CMS56v10 CMS56v11 CMS56v12 No Version Available
Previous Version No Version Available

Release Notes

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 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

  • ​Removed 'day of' from the timing logic to ensure the initial assessment is completed before the procedure and to promote harmonization with CMS66.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CQM-3686

  • 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 THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006): Deleted 2 SNOMED CT codes (33788003, 425443008) 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: Apr 24, 2023