The Centers for Medicare and Medicaid Services (CMS) finalized the ASC-21 rule which includes the addition of the Risk-Standardized Patient-Reported Outcome-Based Performance Measure (THA/TKA PRO-PM) to both the Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) payment system. This final rule emphasizes the importance of utilizing patient-reported outcomes in care delivery by bringing the PRO-PM measure to the outpatient setting.
Starting October 3rd, 2024, providers may begin to collect data for the first round of voluntary reporting. Participating in voluntary reporting ensures you have enough time to test and refine your workflows prior to mandatory deadlines with payment impacts.
What's Involved in the THA/TKA PRO-PM?
The outpatient THA/TKA PRO-PM is significant because it reinforces what we learned last fall with the release of the Inpatient Patient-Reported Outcome Performance Measure (PRO-PM): patient outcomes are important and here to stay. This performance measure will provide healthcare providers with actionable insights into the quality of care patients receive from two common procedures.
Eligible Patient Cohorts:
- Patients must be enrolled in Medicare fee-for-service (FFS) & 65+ years old
- Patients must undergo an Elective Total Knee or Total Hip Arthroplasty
- This must be the patient’s first procedure - revisions and/or fractures do not qualifyThe procedure must be performed at a Hospital Outpatient Department (HOPD) or Ambulatory Surgery Center (ASC)
How are patient outcomes tracked and reported on?
Sites must report a minimum of 45% of all eligible patients with complete pre-op data and matching eligible, post-op data. To measure a positive patient outcome, patients must meet or exceed the substantial clinical benefit (SCB) thresholds outlined in the joint-specific surveys. The SCB thresholds are:
- HOOS, JR >= 22 points
- KOOS, JR >= 20 points
What data sources will be included?
- Patient-reported outcome (PRO) and risk variable data (to identify the measure outcome and some risk variables)
- Administrative claims data (to identify the measure cohort and risk variables)
- Medicare enrollment and beneficiary data (to identify the measure cohort)
How is non-response accounted for?
Since responding to PRO data is voluntary, we understand the importance of accounting for non-response. Therefore, the measure uses a statistical approach called inverse probability weighting (IPW) to consider patient characteristics of all eligible THA/TKA patients to address potential non-response bias.
Ensure you are set up for CMS compliance
Take advantage of the voluntary reporting period to minimize clinical disruptions and streamline processes. Harness tools that:
- Integrate with your EHR to minimize disruption to clinician’s day-to-day.
- Automate data collection to streamline PRO workflows.
- Structure data to comply with new regulations and standards of care.
- Create actionable insights to foster continuous improvement and remain compliant.
There will be three voluntary reporting periods from 2025-2027. In order to qualify patients for the 2025 voluntary reporting cycle, pre-op data must be collected starting on October 3, 2024. Mandatory reporting begins with pre-op data collection in October of 2027. This will impact reimbursement payments in the 2031 calendar year.
PatientIQ recommends participating in the voluntary reporting periods to better understand your patients outcomes data without penalty. Once the mandatory reporting period begins, failure to either report or reach minimum improvement metrics will result in up to a 2% reduction in payments.
