§ 512.413 - Quality measures and reporting for SHFFT model.

§ 512.413 Quality measures and reporting for SHFFT model.

(a) Required measures.

(1) Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty (NQF #1550) (Hip/Knee Complications).

(2) HCAHPS Survey (NQF #0166).

(b) Voluntary measure.

(1) Patient-reported outcomes and limited risk variable data following elective primary THA/TKA.

(2) To be eligible to receive the additional points added to the SHFFT model composite quality score for successful voluntary data submission of patient-reported outcomes and limited risk variable data, as described in § 512.315(d)(1)(iv), SHFFT model participants must submit the THA/TKA patient-reported outcome and limited risk variable data requested by CMS related to the pre- and post-operative periods for elective primary total hip and/or total knee arthroplasty procedures. The data must be submitted within 60 days of the end of the most recent performance period and be accompanied by the patient-reported outcomes and limited risk variable data (eleven elements finalized) as outlined in § 512.315(d)(1)(iv).

(i) For each eligible procedure all eleven risk variable data elements are required to be submitted. The eleven risk variables are as follows:

(A) Date of birth.

(B) Race.

(C) Ethnicity.

(D) Date of admission to anchor hospitalization.

(E) Date of eligible THA/TKA procedure.

(F) Medicare Health Insurance Claim Number.

(G) Body mass index.

(H) Use of chronic (≥ 90 days) narcotics.

(I) Total painful joint count.

(J) Quantified spinal pain.

(K) Single Item Health Literacy Screening (SILS2) questionnaire.

(ii) Participants must also submit the amount of requested THA/TKA patient-reported outcomes data required for each year of the SHFFT model in order to be considered successful in submitting voluntary data.

(A) The amount of requested THA/TKA patient-reported outcomes data to submit, in order to be considered successful increases each subsequent year of the SHFFT model over the 5 years of the model.

(B) A phase-in approach that determines the amount of requested THA/TKA patient-reported outcomes data to submit over the 5 years of the SHFFT model is applied so that in year 1 successful submission of data would mean CMS received all requested THA/TKA patient-reported outcomes and limited risk variable data on both of the following:

(1) Greater than or equal to 60 percent of eligible procedures or greater than or equal to 75 percent eligible patients during the data collection period.

(2) Submission of requested THA/TKA PRO and limited risk variable data is completed within 60 days of the most recent performance period.

(iii) For years 1 through 5 of the model an increasing amount of data is requested by CMS for each performance period as follows:

(A) Year 1 (2017). Submit pre-operative data on primary elective THA/TKA procedures for ≥ 60 percent or ≥ 75 procedures performed between September 1, 2016 through June 30, 2017, unless CMS requests a more limited data set, in which case, submit all requested data elements.

(B) Year 2 (2018). Submit -

(1) Post-operative data on primary elective THA/TKA procedures for ≥ 60 percent or ≥ 75 procedures performed between September 1, 2016 and June 30, 2017; and

(2) Pre-operative data on primary elective THA/TKA procedures for ≥ 70 percent or ≥ 100 procedures performed between July 1, 2017 and June 30, 2018, unless CMS requests a more limited data set, in which case, submit all requested data elements.

(C) Year 3 (2019). Submit -

(1) Post-operative data on primary elective THA/TKA procedures for ≥ 70 percent or ≥ 100 procedures performed between July 1, 2017 and June 30, 2018; and

(2) Pre-operative data on primary elective THA/TKA procedures for ≥ 80 percent or ≥ 200 procedures performed between July 1, 2018 and June 30, 2019, unless CMS requests a more limited data set, in which case, submit all requested data elements.

(D) Year 4 (2020). Submit -

(1) Post-operative data on primary elective THA/TKA procedures for ≥ 80 percent or ≥ 200 procedures performed between July 1, 2018 and June 30, 2019; and

(2) Pre-operative data on primary elective THA/TKA procedures for ≥ 80 percent or ≥ 200 procedures performed between July 1, 2019 and June 30, 2020, unless CMS requests a more limited data set, in which case, submit all requested data elements.

(E) Year 5 (2021). Submit -

(1) Post-operative data on primary elective THA/TKA procedures for ≥ 80 percent or ≥ 200 procedures performed between July 1, 2019 and June 30, 2020; and

(2) Pre-operative data on primary elective THA/TKA procedures for ≥ 80 percent or ≥ 200 procedures performed between July 1, 2020 and June 30, 2021, unless CMS requests a more limited data set, in which case, submit all requested data elements.