Functional Status Assessments for Heart Failure
Measure Information | 2023 Performance Period |
---|---|
CMS eCQM ID | CMS90v12 |
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 any time 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 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 |
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 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. |
Telehealth Eligible | Yes |
Next Version | |
Previous Version |
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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 | |||
Notes |
*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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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated grammar and punctuation to improve readability.
Measure Section: Reference
Source of Change: Measure Lead
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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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Revised the Initial Population header language regarding the timing of the encounters and diagnosis to align with the current logic and to provide clarity.
Measure Section: Initial Population
Source of Change: Measure Lead
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Revised the numerator language and guidance related to the timing of the initial functional status assessment to align with the current logic and to provide clarity.
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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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 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 Measure Authoring Tool (MAT) Global Common Functions Library to v7.0.000.
Measure Section: Multiple Sections
Source of Change: Standards/Technical Update
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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
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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
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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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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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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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 SNOMED CT code (373066001) based on review by technical experts, SMEs, and/or public feedback.
Measure Section: Terminology
Source of Change: Measure Lead