| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS66v10 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 375 |
| 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 |
| 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 |
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. |
| 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 | No Version Available |
| Previous Version |
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 |
|---|---|---|
| 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 |
Data Element Repository
Header
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Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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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
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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
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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
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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
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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
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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.
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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
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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
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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
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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
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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