Functional Status Assessment for Total Hip Replacement

Measure Information	2021 Performance Period
CMS eCQM ID	CMS56v9
NQF Number	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
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	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.
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
Measure 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.
MIPS Quality ID	376
Telehealth Eligible	Yes
Next Version	CMS56v10
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period
Title	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
NQF Number	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
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
Denominator	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.
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
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Measure Steward	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
Measure Type	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
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.
MIPS Quality ID	376	376	376
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS56v10	CMS56v11	No Version Available
Previous Version	No Version Available	CMS56v9	CMS56v10

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Specifications

Attachment	Size
CMS56v9.html	73.44 KB
CMS56v9.zip	86.27 KB
CMS56v9-TRN.xlsx	22.36 KB

Data Element Repository

Data Elements contained within CMS56v9

Value Sets

Value Sets to be used with CMS56v9

Release Notes

CMS56v9-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 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