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Functional Status Assessment for Total Hip Replacement

General eCQM Information

CMS Measure ID CMS56v10
NQF Number Not Applicable
Measure 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

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
Denominator Statement

Equals Initial Population

Denominator Exclusions

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.

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, 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 Exceptions

None

Measure Steward Centers for Medicare & Medicaid Services (CMS)
Domain Person and Caregiver-Centered Experience and Outcomes
Measure Scoring Proportion
Measure Type Process
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 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

Quality ID 376
Meaningful Measure Functional Outcomes
Telehealth Eligible Yes
Previous Version

Release Notes

Header

  • Updated the eCQM version number.

    Measure Section: eCQM Version Number

    Source of Change: Annual Update

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • 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

  • 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

  • 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

  • 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

  • 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

  • Updated Hospice CQL Library to version 3.0.000.

    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.

  • Value set Primary THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006): Added 1 SNOMED CT code (770606008) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Fracture - Lower Body (2.16.840.1.113883.3.464.1003.113.12.1037): Added 1 SNOMED CT code (764932008) based on review by technical experts, SMEs, and/or public feedback. Deleted 3 SNOMED CT codes (208623004, 208627003, 208614002) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement [HOOSJR] (2.16.840.1.113883.3.464.1003.118.12.1210) and replaced with direct reference code LOINC Code (82323-7) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • 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

  • Added value set Online Assessment (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

Last Updated: Jul 08, 2021