This measure is a re-specified version of the measure, “Hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA)” (NQF 1550), which was developed for patients 65 years and older using Medicare claims data. This re-specified measure attributes outcomes to MIPS participating Eligible Clinicians and/or Eligible Clinician Groups (“providers”), rather than to hospitals, and assesses each provider’s complication rate, defined as any one of the specified complications occurring from the date of index admission to 90 days post date of the index admission (the admission included in the measure cohort).
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.20 Testing Data Sources
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1.14 Numerator
The outcome for this measure is any complication occurring during the index admission (not coded present on arrival) to 90 days post-date of the index admission. Complications other than mortality are counted in the measure only if they occur during the index hospital admission or during a readmission. This outcome is identical to that of the original hospital measure. Additional details are provided in S.5 Numerator Details.
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1.15 Denominator
The target population for the measure includes admissions for Medicare FFS beneficiaries who are at least 65 years of age who have undergone elective primary THA and/or TKA procedures.
Attribution of Index Admissions to Eligible Clinicians
Each patient index admission (the admission during which the patient has the eligible THA/TKA procedure), and therefore their outcome (complication or no complication) is attributed to the Eligible Clinician who bills for the procedure (Billing Surgeon). Conceptually, the Billing Surgeon is the Clinician with the primary responsibility for the procedure and procedure related care.
In practice, patients may have different claims for the same procedure, and so the billing surgeon is assigned through an algorithm that resolves ambiguities in billing. The algorithm uses billing claims to identify the clinician(s) who bills for a THA (CPT® code 27130) or TKA (CPT®® code 27447 or CPT® code 27446) (steps 1-3 below). These CPT® codes are representative of the THA and/or TKA procedures included in the measure cohort.
1. If only one clinician bills for a THA (CPT® code 27130) or TKA (CPT® code 27446 or 27447) for a patient, the algorithm identifies and assigns this individual as the Billing Surgeon.
2. If two or more clinicians bill for THA/TKA procedures (CPT® 27130, 27447, or 27446), the algorithm seeks to identify a ‘key’ physician among them. The algorithm identifies and excludes assignment to clinicians who were assistants-at-surgery (assistant surgeon with CPT® modifier 80 or 82, minimum assistant surgeon with CPT® modifier 81). In this step, the algorithm assigns the Billing Surgeon as the clinician who billed for a THA or TKA procedure and is not an assistant-at-surgery.
3. If a single clinician who is not an assistant-at-surgery could not be identified for assignment, then the algorithm identifies whether there is a single clinician who was an orthopedic surgeon (Medicare Specialty Code 20) and assigns this as the Billing Surgeon.
4. If the algorithm cannot identify a Billing Surgeon, it identifies whether an Operator is listed on the institutional claim. The algorithm then defaults assignment to the Operator listed on the institutional claim.
Finally, if a Billing Surgeon or Operator cannot be identified with the steps above, the patient is not assigned to a clinician or group and is excluded from the measure.
Attribution of Index Admissions to an Eligible Clinician Group
CMS needs the flexibility to assign each eligible patient index admission to at least one Eligible Clinician and at least one Eligible Clinician group. This allows them the ability to report at either the Eligible Clinician or the Eligible Clinician Group level. Conceptually, these assignments should represent a consistent group of clinicians. That is, it would be confusing to assign a patient to Eligible Clinician A and also to Eligible Clinician Group B if Eligible Clinician A is not in that Group. The attribution methodology addresses this by using both individual and group identifiers.
Every Medicare Eligible Clinician has a unique National Provider Identifier (NPI). Similarly, every Medicare Eligible Clinician Group has one or more Tax Identification Numbers (TINs), reflecting their practice setting(s). Each Eligible Clinician claim should include both their NPI and a TIN which identifies their “group” (which may consist only of that clinician if they are solo providers). Therefore, we identify clinicians for each patient index admission through the unique National Provider ID (NPI) and Tax ID (TIN) combination listed on a patient’s claim. For a Billing Surgeon, the NPI and TIN are those on the procedure claim used to attribute the patient index admission. To identify the unique TIN/NPI combination for the Operator, the Operator’s NPI is matched to the TIN with the most Part B allowed charges during the index admission or during the measurement year if the Operator did not bill during the index admission. Most NPIs are associated with only one TIN. A Clinician Group is set of Clinicians (NPI-TIN combinations) assigned to the same TIN.
Additional details are provided in S.7 Denominator Details.
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Exclusions
This measure excludes index admissions for patients:
1. Who survived the index admission but without 90-day Medicare part A enrollment post discharge;
2. Who were transferred in to the index hospital;
3. Who leave the hospital against medical advice (AMA);
4. With more than two THA/TKA procedures codes during the index hospitalization; or
5. Who cannot be attributed to a billing surgeon or operator using claims data
After applying the exclusion criteria above, we randomly select one index admission for patients with multiple index admissions in a calendar year. We therefore exclude the other eligible index admissions in that year.
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OLD 1.12 MAT output not attachedAttached
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Most Recent Endorsement ActivityEndorsed Surgery Spring Cycle 2019Initial EndorsementLast Updated
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC EmailSteward Organization Copyright
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Risk AdjustmentRisk adjustment approachOffRisk adjustment approachOffConceptual model for risk adjustmentOffConceptual model for risk adjustmentOff
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6.1.2 Current or Planned Use(s)6.1.3 Current Use(s)
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Planned Use
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