CMS-56 Case Attribution Logic to TINs

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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      Thank you for your inquiry related to CMS56v14: Functional Status Assessment for Total Hip Replacement. Since CMS56v14 is a patient-based measure, reporting eligibility is determined based on the patient's clinical history (including the timing of the THA) rather than the provider who performed the procedure. According to the measure specification, the patient must have had a primary THA between November two years prior to the measurement period and October of the year prior to the measurement period. This includes procedures that may have been performed outside of your facility, if they are documented within a patient's EHR. For a THA to be captured in the measure, it must be documented using one of the codes in the associated value set: Primary THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006). If past THA procedures are documented as having occurred within the specified timeframe using codes from this value set, these data could be captured by the measure.
       
      Direct guidance cannot be provided on which data field within the EHR should be queried for this information. We recommend working with your data vendor to implement the measure according to the measure specification. The eCQM Logic and Implementation Guidance document or other resources on the eCQI Resource Center may be helpful as you move forward with measure implementation.
      Show
      Thank you for your inquiry related to CMS56v14: Functional Status Assessment for Total Hip Replacement. Since CMS56v14 is a patient-based measure, reporting eligibility is determined based on the patient's clinical history (including the timing of the THA) rather than the provider who performed the procedure. According to the measure specification, the patient must have had a primary THA between November two years prior to the measurement period and October of the year prior to the measurement period. This includes procedures that may have been performed outside of your facility, if they are documented within a patient's EHR. For a THA to be captured in the measure, it must be documented using one of the codes in the associated value set: Primary THA Procedure (2.16.840.1.113883.3.464.1003.198.12.1006). If past THA procedures are documented as having occurred within the specified timeframe using codes from this value set, these data could be captured by the measure.   Direct guidance cannot be provided on which data field within the EHR should be queried for this information. We recommend working with your data vendor to implement the measure according to the measure specification. The eCQM Logic and Implementation Guidance document or other resources on the eCQI Resource Center may be helpful as you move forward with measure implementation.
    • CMS0056v14
    • CMS0056v13
    • CMS0056v12
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      Surgical cases are being attributed to a TIN from EHR data records of Surgical History and/or External Procedures. There is a significant number of erroneous cases attributed to a TIN that providers at the TIN have no agency over the patients to complete the two patient reported outcomes surveys.
      Show
      Surgical cases are being attributed to a TIN from EHR data records of Surgical History and/or External Procedures. There is a significant number of erroneous cases attributed to a TIN that providers at the TIN have no agency over the patients to complete the two patient reported outcomes surveys.

      We ran a measure outcomes report from our EHR to validate our outcomes for this measure. In that we found there were 463 total patients in the report for the TIN. We sampled about 25%, n=115, of those cases for the patients that were included into the measure for either Surgical History or External Procedures. Here is a breakdown of what was found. 

       
      Total CMS-56 Patients = 461 * Excluded = 138

      • Met = 88
      • Not Met = 235
      • Met Rate = 27.2%

       
      Sample (~25%) = 115 cases * Excluded = 38

      • Met = 26
      • Not Met = 51
      • Met Rate = 33.8%

       
      Cases that had Surgical History and/or External Procedure for inclusion into the measure = 37 cases (32.2%; 37/115) * Cases that had Surgical History inclusion = 32

      • Cases that had External Procedure inclusion = 10
      • Case Outcome that were Not Met = 26
      • Case Outcome that were Excluded = 11
      • Case Outcome that were Met = 0
      • Cases where the Outcome was correct = 4 (green)
        • 1 Not met
        • 3 Excluded
      • Cases where the Outcome was incorrect (should not be attributed to the SUSDMC TIN) = 33 (red)
        • 25 Not Met
        • 8 Excluded

       
      Correcting the results with the 37 cases audited above, keeping the correct Outcome cases and removing the incorrect Outcome cases, significantly changes performance rate for the measure. * Total cases = 82

      • Not Met = 26
      • Met = 26
      • Excluded = 30
      • New Rate = 50.0%

       
      Our system typically uses Surgical History as a manual entry field to capture patients that had a previous procedure that is not currently represented in the Surgical History because it was done at an outside organization. Procedures that are performed by providers in our TIN are auto-populated to the TIN. The manual entry process can be fraught with errors as patients do not always remember when the exact date the procedure was performed, therefore if it is entered without a date it defaults the date to the date it was entered.
       
      Additionally, the External Procedure field pulls in procedures that were not performed by our TIN. That is why they are call External Procedures. They are performed by other providers outside of our TIN and we have no agency over these patients. They do not see our orthopedic surgeons and we cannot evaluate their pre- and post-op patient reported outcomes surveys.
       
      As you can see through this audit we would be removing a significant number of unmet patients from the total list of those included in the measure if the data was more accurately evaluated. Reasons for this include: * Patients having inappropriate Surgical History dates when the SH was updated with a blank date

      • Patients being included from accurate Surgical History dates but the procedure was not performed at our TIN
      • Patients being pulled in from External Procedures that were not performed at our TIN

      Accurate patient lists for the measure are represented by the Charge field when charges billed through the TIN/NPI for the procedure pull patients into the measure. All of the patients that are accurately represented in the measure are queried through the Charge Standard Check field that our EHR vendor uses. We would recommend investigating the fields that are being checked for inclusion of patients into the measure and strongly consider removing Surgical History and/or External Procedures or more tightly control the meta data surrounding their inclusion. 

      Finally, is it accurate to be evaluating Surgical History and External Procedures to evaluate patient inclusion into the measure for their elective total hip procedures? Where within the data set does it described which data field within the EHR should be evaluated? Or does the EHR vendor just decide which fields to check for this type of procedure? I am unable to find those in the following links:

       

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Jeremy Morgan
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              Created:
              Updated:
              Resolved: