CMS THA/TKA PRO-PM | 3 Reports You Must Have

March 06, 2024


It is imperative for organizations impacted by CMS’ THA/TKA PRO-PM to track PROM capture rate and functional improvement scores.  There are three reports CODE is using that have proven to be ‘mission critical’ to monitor performance: 1) Capture Rate, 2) Data Completeness, and 3) Functional Improvement. If you are collecting PROs, you should be able to pull these reports in less than 10 minutes, and should be reviewing the data on a monthly basis. Here we go:

1. PRO Capture Rate

CMS requires that you have PROs collected pre-op and 1-year post-op on 50% of your inpatient THA/TKA. At CODE, we like to pull three reports that help us monitor capture rate:  1) pre-op capture rate, 2) 3-month post-op and 3) 1-year post-op capture rate  and then a ‘paired’ capture rate. For pre-op, naturally, the higher the capture rate, the better chance you have of meeting the metric. Our goal is to keep pre-op capture at or above 80%. 

In addition to reporting the aggregate number for the site, we like to break the data down by provider, as it helps us identify issues on a more granular level. The next capture rate report we pull is the 3-month and 1-year post-op. I’m sure you are thinking ‘why 3-month when the CMS measure is 1-year?’ There are two reasons: firstly, the 3-month capture rate is a great indicator of what the 1-year capture rate will be and secondly, we also find the functional improvement data interesting at the 3-month mark, so why we are looking at that data set, may as well pull the capture rate report!

voluntary reporting timeline
      Lastly is the paired capture rate. This is the methodology CMS uses which is the total number of patients who have both a pre-op and 1-year completed survey.
voluntary reporting timeline

2. Data Completeness

In addition to the PROs data, other elements go into the 50% data completeness requirement. The good news is the majority of the data elements are available as discrete fields within the EHR, such as Date of Admission and Medicare Provider Number. We recommend running this report on a quarterly basis for the previous quarter’s procedures. Missing elements are often related to process changes, and running this report every quarter ensures that any issues can be resolved well before it comes time to report. There is one measure our clients are struggling with a bit, that is the provider-reported use of Chronic Narcotics. We recommend paying close attention to that measure as you go through this exercise.

3. Functional Improvement Scores

The PRO scores will be made available to the public on CMS’ websites. Anytime something is going to be displayed publicly, it is good to understand what the score displayed will be. When running this report, be sure to filter by inpatient procedures.  In the CODE registry, the pre-op to 1-year post-op delta for THA/TKA is far different between the inpatient and outpatient cohort. That is expected, as inpatient procedures are performed on patients who need that level of care and have more comorbidities, etc.

voluntary reporting timeline

In summary, it is not just enough to collect the surveys. You must be able to run reports and monitor the measure to be successful with THA/TKA PRO-PM. If you are not able to run these reports, now is your time to figure it out. If you are struggling and want to talk through it with an expert, the team at CODE can help.

CODE Can Set You Up For Success

If you are struggling and want to talk through it with an expert,
the team at CODE can help.