| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS90v11 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 377 |
| Description |
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 period and a diagnosis of heart failure that starts before and continues into 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 |
Equals Initial Population |
| Denominator Exclusions |
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. |
| 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 |
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. |
| Telehealth Eligible | Yes |
| Next Version | |
| 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 | 2023 Performance Period | 2024 Performance Period |
|---|---|---|---|---|
| Title | Functional Status Assessments for Congestive Heart Failure | Functional Status Assessments for Heart Failure | Functional Status Assessments for Heart Failure | Functional Status Assessments for Heart Failure |
| CMS eCQM ID | CMS90v10 | CMS90v11 | CMS90v12 | CMS90v13 |
| NQF Number | Not Applicable | 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 |
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. |
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 |
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. | 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 |
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 |
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 |
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. |
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 | 377 |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | CMS90v11 | CMS90v12 | CMS90v13 | No Version Available |
| Previous Version | No Version Available |
*Note: There is a known issue on CMS90v11. See issue EKI-16 on the ONC eCQM Known Issues Dashboard for details.
Data Element Repository
Header
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Removed 'congestive' from the measure title to align with the measure intent.
Measure Section: eCQM Title
Source of Change: Measure Lead
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Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
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Revised the measure description to align with the measure intent and guidance.
Measure Section: Description
Source of Change: Measure Lead
-
Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated the rationale to align with current evidence.
Measure Section: Rationale
Source of Change: Measure Lead
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Updated the guidance language to clarify encounter timing and align with the measure intent.
Measure Section: Guidance
Source of Change: Measure Lead
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Revised the initial population timing language to align with the logic.
Measure Section: Initial Population
Source of Change: Measure Lead
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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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Revised the 'KCCQ Total Assessment Completed' definition name to reflect a similar format in other definitions in the measure.
Measure Section: Definitions
Source of Change: Measure Lead
-
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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Replaced the 'Follow Up Encounter' definition in the initial population with a new definition 'Two Outpatient Encounters during Measurement Period' to align the encounter timing with the measure intent.
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
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Revised the measure CQL library name from FunctionalStatusAssessmentsforCongestiveHeartFailure to FunctionalStatusAssessmentsforHeartFailureto align with the revised measure title. This change will be seen in the measure package and not the human readable specification.
Measure Section: eCQM Identifier (Measure Authoring Tool)
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 Heart Failure (2.16.840.1.113883.3.526.3.376): Added 1 SNOMED CT code (871617000) based on terminology update.
Measure Section: Terminology
Source of Change: Annual Update
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Added value set Online Assessments (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
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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