Functional Status Assessment for Total Hip Replacement

Last updated: May 3, 2018

CMS Measure ID: CMS56v6
Version: 6
NQF Number: None
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 Patient Population:

Patients 18 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 Populationinfo-icon

Denominator Exclusions:

Patients with multiple fractures indicating trauma at the time of the total hip arthroplasty or patients with severe cognitive impairment.

Exclude patients who were in hospice care during the measurement year.

Numerator Statement:

Patients with patient-reported functional status assessment (i.e., VR-12, PROMIS-10-Global Health, HOOS) in the 90 days prior to or on the day of primary THA procedure, and 270 - 365 days after THA procedure

Numerator Exclusions:

Not Applicable

Denominator Exceptions:

None

Measure Steward: Centers for Medicare and Medicaid Services (CMS)
Domain: Person and Caregiver-Centered Experience and Outcomes
Next Version:
Previous Version:
Improvement Notation:

A higher score indicates better quality

Guidance:

A Functional Status Assessment (FSA) is based on administration of a validated instrument to eligible patients that asks patients to answer questions related to various domains including: pain, physical function, emotional well-being, health-related quality of life, symptom acuity.

The same FSA instrument must be used for the initial and follow-up assessment.

Notes: Value Set content updated Sept 2017

Specifications

Release Notes

Header

  • ​Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Modified the Measure Description to include the updated timings for baseline and follow-up functional status assessments.

    Measure Section: Description

    Source of Change: Measure Lead

  • ​Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • ​Updated Disclaimer.

    Measure Section: Disclaimer

    Source of Change: Measure Lead

  • Updated References.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Updated Guidance.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Simplified the timing restrictions for the primary surgical procedure to ensure it takes place in the year prior to the measurement period. The timing for the outpatient encounter is no longer tied to the primary surgical procedure; the encounter only needs to take place during the measurement year.

    Measure Section: Initial Populationinfo-icon

    Source of Change: Measure Lead

  • ​Updated the exclusion statement in the header to exclude patients in hospice care from the Denominatorinfo-icon. Measures that focus on screenings and procedures may not be appropriate or a priority for those who are at end of life (ie, on hospice).

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Removed VR-36 and PROMIS-29 tools from list of approved functional status assessments (FSAs) for CMS56 and CMS66. Updated the timing for the baseline and follow-up FSAs to 90 days prior to surgical procedure and 270-365 days after surgical procedure, respectively.

    Measure Section: Numeratorinfo-icon

    Source of Change: Measure Lead

Logic

  • Simplified the timing restrictions for the primary surgical procedure to ensure it takes place in the year prior to the measurement period. The timing for the outpatient encounter is no longer tied to the primary surgical procedure; the encounter only needs to take place during the measurement year.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added new lines of logic to the Denominator Exclusions for all NCQA-stewarded measures (except CMS82) to ensure patients in hospice care are excluded from the Denominator.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • Removed VR-36 and PROMIS-29 tools from list of approved functional status assessments (FSAs) by removing LOINC codes from value setinfo-icon Functional Status Assessment for Hip Replacement. Updated the timing for the initial and follow-up FSAs to 90 days prior to surgical procedure and 270-365 days after surgical procedure, respectively.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Replaced the 'ends before start of' logical operator to address situations where time stamps are not attached to procedures, diagnosis, and immunizations. Wherever applicable, the operators have been changed to 'ends before or concurrent with start of'.

    Measure Section: Numerator

    Source of Change: JIRA (CQMinfo-icon-1936)

  • Replaced 'Functional Status, Performed' datatype with 'Assessment, Performed' datatype to conform with QDMinfo-icon 4.3 changes.

    Measure Section: Numerator

    Source of Change: QDM Standards

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value setsinfo-icon.

  • Value set Functional Status Assessment for Hip Replacement (2.16.840.1.113883.3.464.1003.118.12.1029): Deleted 50 LOINC codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Fracture - Lower Body (2.16.840.1.113883.3.464.1003.113.12.1037): Added 2105 ICD10CM codes and deleted 30 ICD10CM codes. Deleted 4 SNOMEDCT codes (208534007, 428000009, 429186005, 429552008). Deleted 71 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307): Added Encounter Inpatient.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15): Added Hospice care ambulatory.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Health Care Facility for Hospice Care (2.16.840.1.113883.3.117.1.7.1.207): Added Discharged to Health Care Facility for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Discharged to Home for Hospice Care (2.16.840.1.113883.3.117.1.7.1.209): Added Discharged to Home for Hospice Care.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Fracture - Lower Body (2.16.840.1.113883.3.464.1003.113.12.1037): Added 4 SNOMEDCT codes (428000009, 429186005, 429552008, 447931000124101).

    Measure Section: QDM Data Elements

    Source of Change: 2018 Addendum

External Resources