| 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 |
Compare eCQM Versions
The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.
Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.
| 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 |
Data Element Repository
Header
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Updated eCQM Version Number.
Measure Section: eCQM Version Number
Source of Change: Standards Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated rationale to change 'elderly' to 'older adults' to use a more neutral description.
Measure Section: Rationale
Source of Change: Measure Lead
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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
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Updated references.
Measure Section: Reference
Source of Change: Standards Update
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Added text to identify the Quality Data Model (QDM) version used in the measure specification.
Measure Section: Guidance
Source of Change: Standards Update
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Added text to indicate whether the measure is patient-based or episode-based.
Measure Section: Guidance
Source of Change: Standards Update
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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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
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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