Functional Status Assessment for Total Knee Replacement

Measure Information	2022 Performance Period
CMS eCQM ID	CMS66v10
NQF Number	Not Applicable
Description	Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) 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 knee arthroplasty (TKA) in the year prior to the measurement period and who had an outpatient encounter during the measurement period
Denominator	Equals Initial Population
Denominator Exclusions	Exclude patients with two or more fractures indicating trauma at the time of the total knee 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, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA 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	375
Telehealth Eligible	Yes
Next Version	No Version Available
Previous Version	CMS66v9

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Measure Information	2021 Performance Period	2022 Performance Period
Title	Functional Status Assessment for Total Knee Replacement	Functional Status Assessment for Total Knee Replacement
CMS eCQM ID	CMS66v9	CMS66v10
NQF Number	Not Applicable	Not Applicable
Description	Percentage of patients 18 years of age and older who received an elective primary total knee arthroplasty (TKA) 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 knee arthroplasty (TKA) 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 knee arthroplasty (TKA) 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 knee arthroplasty (TKA) 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
Denominator Exclusions	Patients with two or more fractures indicating trauma at the time of the total knee 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 knee 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, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA 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, Knee Injury and Osteoarthritis Outcome Score [KOOS], KOOS Jr.) in the 90 days prior to or on the day of the primary TKA procedure, and in the 270 - 365 days after the TKA procedure
Numerator Exclusions	Not Applicable	Not Applicable
Denominator Exceptions	None	None
Measure Steward	Centers for Medicare & Medicaid Services (CMS)	Centers for Medicare & Medicaid Services (CMS)
Measure Scoring	Proportion measure	Proportion measure
Measure Type	Process measure	Process measure
Improvement Notation	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.
MIPS Quality ID	375	375
Telehealth Eligible	Yes	Yes
Next Version	CMS66v10	No Version Available
Previous Version	No Version Available	CMS66v9

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CMS66v10.html	85.32 KB
CMS66v10.zip	98.77 KB
CMS66v10-TRN.xlsx	19.09 KB

Data Element Repository

Data Elements contained within CMS66v10

Value Sets

Value Sets to be used with CMS66v10

Release Notes

CMS66v10-TRN.xlsx

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 TKA Procedure (2.16.840.1.113883.3.464.1003.198.12.1007): Added 4 SNOMED CT codes (444463001, 609588000, 764931001, 764932008) 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 Knee Injury and Osteoarthritis Outcome Score for Joint Replacement [KOOSJR] (2.16.840.1.113883.3.464.1003.118.12.1218) with direct reference code LOINC code (82324-5) 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