| Measure Information | 2023 Performance Period |
|---|---|
| CMS eCQM ID | CMS56v11 |
| NQF Number | Not Applicable |
| MIPS Quality ID | 376 |
| Description |
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 |
| 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 |
| 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 |
| Numerator Exclusions |
Not Applicable |
| Denominator |
Equals Initial Population |
| Denominator Exclusions |
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. |
| 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 5.6. Please refer to the QDM page 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 Assessment for Total Hip Replacement | Functional Status Assessment for Total Hip Replacement | Functional Status Assessment for Total Hip Replacement | Functional Status Assessment for Total Hip Replacement |
| CMS eCQM ID | CMS56v9 | CMS56v10 | CMS56v11 | CMS56v12 |
| NQF Number | Not Applicable | 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 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 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 |
Equals Initial Population |
| Denominator Exclusions | Patients with two or more fractures indicating trauma at the time of the total hip 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 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 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 |
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 |
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. |
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 | 376 |
| Telehealth Eligible | Yes | Yes | Yes | Yes |
| Next Version | CMS56v10 | CMS56v11 | CMS56v12 | No Version Available |
| Previous Version | No Version Available |
Data Element Repository
Header
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Revised the description to better capture the measure intent and logic surrounding the age requirement and to provide clarity and alignment across the header and logic.
Measure Section: Description
Source of Change: Measure Lead
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated version number of the Quality Data Model (QDM) used in the measure specification to v5.6.
Measure Section: Guidance
Source of Change: Standards/Technical Update
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Updated the narrative to exclude patients who have 2 lower body fractures within exactly 24 hours of the total hip arthroplasty (THA) to better meet the measure intent.
Measure Section: Denominator Exclusions
Source of Change: ONC Project Tracking System (JIRA): CQM-4858
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Updated grammar and punctuation to improve readability.
Measure Section: Multiple Sections
Source of Change: Measure Lead
Logic
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Updated the timing precision in the definitions from datetime to date by adding 'day of', 'date from', and/or function 'ToDateInterval' to align with the measure intent.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the measure logic to exclude patients who have 2 lower body fractures within exactly 24 hours of the THA to better meet the measure intent.
Measure Section: Definitions
Source of Change: ONC Project Tracking System (JIRA): CQM-4858
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Updated the logic to add the 'NormalizeInterval' function to additional QDM datatypes to decrease implementation burden due to variable use of timing attributes.
Measure Section: Definitions
Source of Change: Measure Lead
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Added QDM datatypes Encounter, Performed and Assessment, Performed and associated logic to the Hospice.'Has Hospice Services' definition to provide additional approaches for identifying patients receiving hospice services.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the 'HOOSJr Total Assessment Completed' definition name to align with the modeling across similar measures.
Measure Section: Definitions
Source of Change: Measure Lead
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Updated the version of the Quality Data Model (QDM) to 5.6 and Clinical Quality Language (CQL) to 1.5.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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Updated the version number of the Hospice Library to v4.0.000.
Measure Section: Multiple Sections
Source of Change: Measure Lead
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Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical 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/Technical Update
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Replaced the Global.CalendarAgeInYearsAt function with the native CQL function AgeInYearsAt to take advantage of existing CQL features and increase human readability. As a result of this change, the LOINC code 21112-8 is no longer required and has been removed from the Terminology section of the human readable specification.
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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Replaced value set Hospice Care Ambulatory (2.16.840.1.113762.1.4.1108.15) with value set Hospice Care Ambulatory (2.16.840.1.113883.3.526.3.1584) 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 Hospice Encounter (2.16.840.1.113883.3.464.1003.1003) 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 Lower Body Fracture (2.16.840.1.113883.3.464.1003.113.12.1037): Deleted 1 SNOMED CT code (764932008) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
-
Removed direct reference code LOINC code (21112-8) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Added direct reference code LOINC code (45755-6) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead
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Added direct reference code SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead