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Functional Status Assessment for Total Hip Replacement

Compare Versions of: "Functional Status Assessment for Total Hip Replacement"

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.

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Measure Information 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
CMS eCQM ID CMS56v10 CMS56v11 CMS56v12
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 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 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

Denominator Exclusions 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 300 - 425 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 5.6. 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
Telehealth Eligible Yes Yes Yes
Next Version No Version Available
Previous Version No Version Available

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Replaced 'overlaps' or 'overlapping' in the denominator exclusions with plain language to clarify the measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

Logic

  • Added online assessments and telephone visits as appropriate encounters based on the increased use of telehealth services.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (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 the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Hospice CQL Library to version 3.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

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 Primary THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006): Added 1 SNOMED CT code (770606008) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Fracture - Lower Body (2.16.840.1.113883.3.464.1003.113.12.1037): Added 1 SNOMED CT code (764932008) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (208623004, 208627003, 208614002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement [HOOSJR] (2.16.840.1.113883.3.464.1003.118.12.1210) and replaced with direct reference code LOINC Code (82323-7) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Telephone Visits (2.16.840.1.113883.3.464.1003.101.12.1080) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Online Assessment (2.16.840.1.113883.3.464.1003.101.12.1089) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Feb 13, 2024