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Thank you for your inquiry about CMS56v12 Functional Status Assessment for Total Hip Replacement. The current logic specifies that the denominator qualifying encounter and total hip arthroplasty (THA) do not need to be completed by the same clinician. THAs may count towards the denominator if they are performed within the required time frame and documented via the QDM datatype "Procedure Performed" using the code found in the "Primary THA Procedure” value set (2.16.840.1.113883.3.464.1003.198.12.1006).

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Thank you for your inquiry about CMS56v12 Functional Status Assessment for Total Hip Replacement. The current logic specifies that the denominator qualifying encounter and total hip arthroplasty (THA) do not need to be completed by the same clinician. THAs may count towards the denominator if they are performed within the required time frame and documented via the QDM datatype "Procedure Performed" using the code found in the "Primary THA Procedure” value set (2.16.840.1.113883.3.464.1003.198.12.1006).
2024 Performance Period EC eCQMs:

CMS0056v12
2023 Performance Period EC eCQMs:

CMS0056v11
Impact:
inflated denominator

Should this measure be limited to patients that received their THA from the reporting clinician or group?

Similar to how CMS133 calls out in the guidance, "This measure is to be reported by the clinician performing the cataract surgery procedure"

We receive procedure codes from external clinicians which is inflating our denominator.