Last updated: June 9, 2017
| 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 Population |
| 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 & Medicaid Services (CMS) |
| Domain: | Person and Caregiver-Centered Experience and Outcomes |
| Previous Version: | Functional Status Assessment for Total Hip Replacement |
| 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. |
Specifications
CMS56v6_0.html
CMS56v6_0.xml- CMS56v6_SimpleXML_0.xml
EP_EC_CMS56v6_NQFXXXX_FSA_Hip_Replacement_0.zip
CMS56v6_TRN_05.05.17_0.xlsx
Release Notes
Header
Incremented eMeasure Version number.
Section: eMeasure Version number
Source: Measure Lead
Modified the Measure Description to include the updated timings for baseline and follow-up functional status assessments.
Section: Description
Source: Measure Lead
Updated Copyright.
Section: Copyright
Source: Annual Update
Updated Disclaimer.
Section: Disclaimer
Source: Measure Lead
Updated References.
Section: Reference
Source: Measure Lead
Updated Guidance.
Section: Guidance
Source: 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.
Section: Initial Population
Source: Measure Lead
Updated the exclusion statement in the header to exclude patients in hospice care from the Denominator. 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).
Section: Denominator Exclusions
Source: 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.
Section: Numerator
Source: 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.
Section: Initial Population
Source: 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.
Section: Denominator Exclusions
Source: Measure Lead
Removed VR-36 and PROMIS-29 tools from list of approved functional status assessments (FSAs) by removing LOINC codes from value set 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.
Section: Numerator
Source: 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'.
Section: Numerator
Source: JIRA (CQM-1936)
Replaced 'Functional Status, Performed' datatype with 'Assessment, Performed' datatype to conform with QDM 4.3 changes.
Section: Numerator
Source: 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 sets.
Value set Functional Status Assessment for Hip Replacement (2.16.840.1.113883.3.464.1003.118.12.1029): Deleted 50 LOINC codes.
Section: None
Source: None
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.
Section: None
Source: None
Value set Encounter Inpatient (2.16.840.1.113883.3.666.5.307): Added Encounter Inpatient.
Section: None
Source: None
Value set Hospice care ambulatory (2.16.840.1.113762.1.4.1108.15): Added Hospice care ambulatory.
Section: None
Source: None
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.
Section: None
Source: None
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.
Section: None
Source: None