Functional Status Assessments for Congestive Heart Failure

Measure Information	2021 Performance Period
CMS eCQM ID	CMS90v10
NQF Number	Not Applicable
Description	Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Initial Population	Patients 18 years of age and older who had two outpatient encounters during the measurement year and a diagnosis of congestive heart failure
Denominator	Equals Initial Population
Denominator Exclusions	Exclude 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]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, PROMIS-29) present in the EHR two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial FSA
Numerator Exclusions	Not Applicable
Denominator Exceptions	None
Measure Steward	Centers for Medicare & Medicaid Services (CMS)
Quality 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	Initial functional status assessment (FSA) and encounter: The initial FSA is the first FSA that occurs two weeks before or during the first encounter in the first 185 days of the measurement year. Follow-up FSA: The follow-up FSA must be completed at least 30 days but no more than 180 days after the initial FSA. 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 5.5. Please refer to the eCQI resource center for more information on the QDM.
MIPS Quality ID	377
Meaningful Measure	Functional Outcomes
Telehealth Eligible	Yes
Next Version	CMS90v11
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period
Title	Functional Status Assessments for Congestive Heart Failure	Functional Status Assessments for Heart Failure	Functional Status Assessments for Heart Failure
CMS eCQM ID	CMS90v10	CMS90v11	CMS90v12
NQF Number	Not Applicable	Not Applicable	Not Applicable
Description	Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments	Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments	Percentage of patients 18 years of age and older with heart failure who completed initial and follow-up patient-reported functional status assessments
Initial Population	Patients 18 years of age and older who had two outpatient encounters during the measurement year and a diagnosis of congestive heart failure	Patients 18 years of age and older who had two outpatient encounters during the measurement period and a diagnosis of heart failure that starts before and continues into the measurement period.	Patients 18 years of age and older who had two outpatient encounters during the measurement period and a diagnosis of heart failure that starts any time before and continues into the measurement period.
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Exclude patients with severe cognitive impairment that overlaps the measurement period. Exclude patients whose hospice care overlaps the measurement period.	Exclude patients with severe cognitive impairment in 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 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]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, PROMIS-29) present in the EHR two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial FSA	Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, PROMIS-29) present in the EHR two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial FSA	Patients with patient-reported functional status assessment results (i.e., Veterans RAND 12-item health survey [VR-12]; VR-36; Kansas City Cardiomyopathy Questionnaire [KCCQ]; KCCQ-12; Minnesota Living with Heart Failure Questionnaire [MLHFQ]; Patient-Reported Outcomes Measurement Information System [PROMIS]-10 Global Health, PROMIS-29) present in the EHR within two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial FSA
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)
Quality Domain	Person and Caregiver-Centered Experience and Outcomes	Person and Caregiver-Centered Experience and Outcomes	Person and Caregiver-Centered Experience and Outcomes
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	Initial functional status assessment (FSA) and encounter: The initial FSA is the first FSA that occurs two weeks before or during the first encounter in the first 185 days of the measurement year. Follow-up FSA: The follow-up FSA must be completed at least 30 days but no more than 180 days after the initial FSA. 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 5.5. Please refer to the eCQI resource center for more information on the QDM.	Initial functional status assessment (FSA) and encounter: The initial FSA is an FSA that occurs two weeks before or during an encounter, in the 180 days or more before the end of the measurement period. Follow-up FSA: The follow-up FSA must be completed at least 30 days but no more than 180 days after the initial FSA. 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 5.5. Please refer to the eCQI resource center for more information on the QDM.	Initial functional status assessment (FSA) and encounter: The initial FSA is an FSA that occurs within two weeks before or during an encounter, in the 180 days or more before the end of the measurement period. Follow-up FSA: The follow-up FSA must be completed at least 30 days but no more than 180 days after the initial FSA. 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	377	377	377
Meaningful Measure	Functional Outcomes	Functional Outcomes	Functional Outcomes
Telehealth Eligible	Yes	Yes	Yes
Next Version	CMS90v11	CMS90v12	No Version Available
Previous Version	No Version Available	CMS90v10	CMS90v11

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Data Element Repository

Data Elements contained within CMS90v10

Value Sets

Value Sets to be used with CMS90v10

Release Notes

CMS90v10-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 clinical recommendation statement to align with updated clinical 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

Updated timing of congestive heart failure (CHF) diagnosis in the initial population logic so it overlaps before the Measurement Period to align with measure intent.

Measure Section: Initial Population

Source of Change: Measure Lead
Changed the timing of the encounter from the start of the measurement period to the end of the measurement period to eliminate the need to adjust the number of days for leap years.

Measure Section: Numerator

Source of Change: Measure Lead
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
Changed measurement period for the Veterans RAND 12 Item Health Survey (VR-12) to allow the initial functional status assessment (FSA) to occur prior to the measurement period when the encounter occurs within the first few days of the measurement period to align with measure intent.

Measure Section: Definitions

Source of Change: ONC Project Tracking System (Jira): CQM-3772
Changed the timing of the follow-up functional status assessment (FSA) in relation to the when the initial FSA is performed and not the encounter to improve alignment with the measure intent.

Measure Section: Definitions

Source of Change: ONC Project Tracking System (Jira): CQM-3787
Updated timing of congestive heart failure (CHF) diagnosis in the initial population logic so it overlaps before the Measurement Period to align with measure intent.

Measure Section: Definitions

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 logic for follow-up assessments to relate the follow-up assessments to the initial assessment rather than the encounter to improve alignment with the measure intent.

Measure Section: Definitions

Source of Change: ONC Project Tracking System (Jira): CQM-3786
Updated logic for the Kansas City Cardiomyopathy Questionnaire (KCCQ) functional status assessment to allow reporting for the 6 domain subcategories or the total score to increase reportability.

Measure Section: Definitions

Source of Change: ONC Project Tracking System (Jira): CQM-3612
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.

Replaced value set Severe Dementia (2.16.840.1.113883.3.526.3.1025) with direct reference code SNOMED CT Code (428351000124105) to align with best practices for replacing single code value sets with direct reference codes.

Measure Section: Terminology

Source of Change: Measure Lead
Value set Heart Failure (2.16.840.1.113883.3.526.3.376): Deleted 24 ICD-9-CM codes. Removed ICD-9 codes from all measures that do not have lookback periods or removed ICD-9 codes from all measures with lookback period for which the ICD-9 codes were no longer relevant.

Measure Section: Terminology

Source of Change: Annual Update
Removed direct reference code LOINC Code (72188-6) due to redundancy with other KCCQ summary components. Added direct reference codes LOINC Codes (72194-4, 71940-1) for the Kansas City Cardiomyopathy Questionnaire (KCCQ) functional status assessment to allow reporting for the 6 domain subcategories or the total score to increase reportability.

Measure Section: Terminology

Source of Change: Measure Lead