2023 # 470 Functional Status After Primary Total Knee Replacement

CMS Measure ID: #470

Collection Type: CQM

Reporting Frequency: Every visit

Outcome: Yes

High Priority: Yes

NQS Domain: Person and Caregiver-Centered Experience Outcomes

Measure Age: > 2 years

Instructions

This measure is to be submitted each time a patient undergoes a total knee replacement during the denominator identification period. This measure may be submitted by Merit-based Incentive Payment System (MIPS) eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.

NOTE: This measure is a target-based measure, where the numerator is met by having a one-year postoperative Oxford Knee Score (OKS) greater than or equal to 37 or a KOOS, JR. score greater than or equal to 71. It is expressed as a proportion or rate. Patients having received a primary total knee replacement procedure who are not assessed for functional status postoperatively remain in the denominator and are considered as not meeting the target. The measure intent is that MIPS eligible clinicians will submit all denominator eligible procedures for performance calculation.

Measure Submission Type:
Measure data may be submitted by individual MIPS eligible clinicians, groups, or third-party intermediaries. The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions as allowed by the measure. The quality-data codes listed do not need to be submitted by MIPS eligible clinicians, groups, or third-party intermediaries that utilize this modality for submissions; however, these codes may be submitted for those third party intermediaries that utilize Medicare Part B claims data.

Description

For patients age 18 and older who had a primary total knee replacement procedure, functional status is rated by the patient as greater than or equal to 37 on the Oxford Knee Score (OKS) or a 71 or greater on the KOOS, JR. tool at one year (9 to 15 months) postoperatively

Denominator

Patients 18 years of age or older as of October 1 of the denominator identification period who had a total knee replacement procedure performed during the denominator identification period

Definition:
Denominator Identification Period – The twelve-month period in which eligible patients have a denominator eligible procedure. This allows for enough time for a follow-up assessment to occur during the twelve-month performance period. The denominator identification period includes dates of procedure 10/1/2021 to 9/30/2022.

Denominator Criteria (Eligible Cases):
Patients aged ≥ 18 years by October 1 of the Denominator Identification Period

AND

Patient procedure during performance period (CPT): 27445, 27446, 27447

WITHOUT

Telehealth Modifier (including but not limited to): GQ, GT, 95, POS 02

Numerator

All eligible patients whose functional status is greater than or equal to 37 on the Oxford Knee Score (OKS) or greater than or equal to 71 on the KOOS, JR. patient reported outcome tool at one year (9 to 15 months) postoperatively

Definitions:
Measure Assessment Period (Performance Period) – The period of time following the procedure date that is in which a postoperative Oxford Knee Score (OKS) or KOOS, JR. functional status score can be obtained reflecting a one year post operative assessment with a 9 to 15 month window. If more than one postoperative assessment was obtained during the 9 to 15 month window, use the most recent score during the allowable timeframe.
Postoperative Assessment Oxford Knee Score (OKS) – A postoperative Oxford Knee Score (OKS) functional assessment score can be obtained from the patient one year (9 to 15 months) after the date of procedure. Assessment scores obtained via a telephone screening or prior to 9 months and after 15 months postoperatively will not be used for measure calculation.
Oxford Knee Score (OKS) Patient Reported Outcome Tool – The Oxford Knee Score (OKS) is a 12-item patient-reported outcome (PRO) tool PRO specifically designed and developed to assess function and pain after total knee replacement (TKR) surgery (arthroplasty). It is short, reproducible, valid and sensitive to clinically important changes. The OKS was designed to be completed by the patient thus minimizing potential bias unwittingly introduced by surgeons when assessing the results themselves. The PRO was designed and developed by researchers at Oxford University Innovation and the University of Oxford. A copy of the tool can be obtained below or at the following link: https://innovation.ox.ac.uk/outcome-measures/oxford-knee-score-oks/. Indicate that this tool is for use in a CMS program and licensing fees should be waived. https://innovation.ox.ac.uk/clinical-outcomes/information-for-cms-members/
OKS Target – A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their functional status score as greater than or equal to 37.
KOOS, JR. – The KOOS, JR. was developed from the original long version of the Knee injury and Osteoarthritis Outcome Score (KOOS) survey using Rasch analysis. The KOOS, JR. contains 7 items from the original KOOS survey. Items are coded from 0 to 4, none to extreme respectively. KOOS, JR. is scored by summing the raw response (range 0-28) and then converting it to an interval score using the table provided below. The interval score ranges from 0 to 100 where 0 represents total knee disability and 100 represents perfect knee health. This short form tool was developed by Stephen Lyman, PhD at the Hospital for Specialty Surgery in 2017. https://www.hss.edu/hoos-jr-koos-jr-outcomes-surveys.asp
KOOS, JR. Target – A patient who is assessed postoperatively at one year (9 to 15 months) after the procedure rates their functional status score as greater than or equal to 71.

NUMERATOR NOTE: The following situations are those in which the numerator targets cannot be reached and Performance Not Met M1046 or M1141 is submitted:
• Oxford Knee Score (OKS) or Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.) is not administered postoperatively at one year (9 to 15 Months)
• Functional status is measured using a different patient-reported functional status tool or Oxford Knee Score (OKS) or Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.)
• Postoperative Oxford Knee Score (OKS) or Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.) is administered less than 9 Months or greater than 15 Months
• Postoperative Oxford Knee Score (OKS) is less than 37 or Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.) is less than 71

Numerator Options:
Performance Met: Functional status measured by the Oxford Knee Score (OKS) at one year (9 to 15 months) postoperatively was greater than or equal to 37 or Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.) was greater than or equal to 71 (M1045)

OR

Performance Not Met: Functional status was not measured by the Oxford Knee Score (OKS) or the Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.) at one year (9 to 15 months) postoperatively (M1141)

OR

Performance Not Met: Functional status measured by the Oxford Knee Score (OKS) at one year (9 to 15 months) postoperatively was less than 37 or the Knee injury and Osteoarthritis Outcome Score Joint Replacement (KOOS, JR.) was less than 71 postoperatively (M1046)