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Functional Status Assessment for Total Knee Replacement

Measure Information 2023 Performance Period
CMS Measure ID CMS66v11
NQF Number Not Applicable
Measure Description

Percentage of patients 19 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 Statement

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 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 Statement

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)
Quality Domain Person and Caregiver-Centered Experience and Outcomes
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.

MIPS Quality ID 375
Meaningful Measure Functional Outcomes
Telehealth Eligible Yes
Next Version No Version Available
Previous Version

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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 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS66v9 CMS66v10 CMS66v11
NQF Number Not Applicable Not Applicable Not Applicable
Measure 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

Percentage of patients 19 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

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 Statement

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 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. Exclude patients with two or more fractures indicating trauma in the 24 hours before or at the start 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 Statement

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

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

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)
Quality Domain Person and Caregiver-Centered Experience and Outcomes Person and Caregiver-Centered Experience and Outcomes Person and Caregiver-Centered Experience and Outcomes
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 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) 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.

MIPS Quality ID 375 375 375
Meaningful Measure Functional Outcomes Functional Outcomes Functional Outcomes
Telehealth Eligible Yes Yes Yes
Next Version CMS66v10 CMS66v11 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Revised the description to capture the measure intent and logic surrounding the age requirement to provide clarity and alignment across the header and logic.

    Measure Section: Description

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated grammar and punctuation to improve readability.

    Measure Section: Reference

    Source of Change: Measure Lead

  • 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

  • Updated the narrative to exclude patients who have 2 lower body fractures within exactly 24 hours of the total knee arthroplasty (TKA) to better meet the measure intent.

    Measure Section: Denominator Exclusions

    Source of Change: ONC Project Tracking System (JIRA): CQM-4858

Logic

  • 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

  • Updated the measure logic to exclude patients who have 2 lower body fractures within exactly 24 hours of the TKA to better meet the measure intent.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (JIRA): CQM-4858

  • 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

  • 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

  • Updated the 'KOOSJr Total Assessment Completed' definition name to align with the modeling across similar measures.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • 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

  • Updated the version number of the Hospice Library to v4.0.000.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • 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

  • 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.

  • 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

  • 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

  • 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

  • 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

  • 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

Last Updated: May 04, 2022