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Functional Status Assessments for Congestive Heart Failure

General eCQM Information

CMS Measure ID CMS90v10
NQF Number Not Applicable
Measure 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

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
Denominator Statement

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.

Numerator Statement

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 Exceptions

None

Measure Steward Centers for Medicare & Medicaid Services (CMS)
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

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.

Quality ID 377
Meaningful Measure Functional Outcomes
Telehealth Eligible Yes
Next Version
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Release Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated clinical recommendation statement to align with updated clinical guidelines.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated clinical recommendation statement to define Veterans RAND 12-Item Health Survey (VR-12), Patient-Reported Outcomes Measurement Information System (PROMIS), and Knee Injury and Osteoarthritis Outcome Score (KOOS) assessment types.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Updated Guidance to use the same functional status assessment (FSA) instrument for the initial and follow-up assessments to promote harmonization between CMS56, CMS66 and CMS90.

    Measure Section: Guidance

    Source of Change: Measure Lead

Logic

  • ​Updated timing of congestive heart failure (CHF) diagnosis in the initial population logic so it overlaps before the Measurement Period to align with measure intent.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • ​Changed the timing of the encounter from the start of the measurement period to the end of the measurement period to eliminate the need to adjust the number of days for leap years.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Standardized the use of 'Follow Up' in definition names to promote harmonization between CMS56, CMS66 and CMS90.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • ​Changed measurement period for the Veterans RAND 12 Item Health Survey (VR-12) to allow the initial functional status assessment (FSA) to occur prior to the measurement period when the encounter occurs within the first few days of the measurement period to align with measure intent.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CQM-3772

  • ​Changed the timing of the follow-up functional status assessment (FSA) in relation to the when the initial FSA is performed and not the encounter to improve alignment with the measure intent.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CQM-3787

  • ​Updated timing of congestive heart failure (CHF) diagnosis in the initial population logic so it overlaps before the Measurement Period to align with measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added the 'Max' operator to ensure the time of the last assessment component is used in relation to other events (applicable for all assessment types) and improve alignment with measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Standardized the use of 'Follow Up' in definition names to promote harmonization between CMS56, CMS66 and CMS90.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated logic for follow-up assessments to relate the follow-up assessments to the initial assessment rather than the encounter to improve alignment with the measure intent.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CQM-3786

  • Updated logic for the Kansas City Cardiomyopathy Questionnaire (KCCQ) functional status assessment to allow reporting for the 6 domain subcategories or the total score to increase reportability.

    Measure Section: Definitions

    Source of Change: ONC Project Tracking System (Jira): CQM-3612

  • Updated timing logic for the follow-up assessment to use 'in Interval' to simplify logic and promote harmonization between measures.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Clinical Quality Language (CQL) Library version update: Updated version number of the Hospice Library (Hospice-2.2.000).

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated CQL expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards 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 Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

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 Severe Dementia (2.16.840.1.113883.3.526.3.1025) with direct reference code SNOMED CT Code (428351000124105) to align with best practices for replacing single code value sets with direct reference codes.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Heart Failure (2.16.840.1.113883.3.526.3.376): Deleted 24 ICD-9-CM codes. Removed ICD-9 codes from all measures that do not have lookback periods or removed ICD-9 codes from all measures with lookback period for which the ICD-9 codes were no longer relevant.

    Measure Section: Terminology

    Source of Change: Annual Update

  • Removed direct reference code LOINC Code (72188-6) due to redundancy with other KCCQ summary components. Added direct reference codes LOINC Codes (72194-4, 71940-1) for the Kansas City Cardiomyopathy Questionnaire (KCCQ) functional status assessment to allow reporting for the 6 domain subcategories or the total score to increase reportability.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: May 05, 2021