eCQM / NQF #:
CMS90v8 / XXXX
Measure: Percentage of patients 18 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments
Numerator: Patients with patient-reported functional status assessment results (ie, VR-12; VR-36; KCCQ; PROMIS-10 Global Health, PROMIS-29) present in the EHRinfo-icon two weeks before or during the initial FSA encounter and results for the follow-up FSA at least 30 days but no more than 180 days after the initial functional status assessment
Denominator: Patients 18 years of age and older who had two outpatient encounters during the measurement year and a diagnosis of congestive heart failure
Denominator Exclusion: Exclude patients with severe cognitive impairment and patients who were in hospice care during the measurement year.
Domain: Person and Caregiver-Centered Experience and Outcomes

In ChartMaker Clinical:

In order to qualify for this measure, the provider must have seen the patient (age 18 and older) at least two times during the reporting period and have the appropriate information documented in the chart:

Required Data Elements for the Denominator:

Required Data Elements for the Numerator:


Exclusion includes patients with Severe Cognitive Impairment or patients who were in hospice care during the measurement year.  In order to meet the requirements for this exclusion, the appropriate information must be documented in the chart:

At least one of the following:


•  The patient must be at least 65 years of age before the start of the measurement period.

•  Initial encounter is defined as the first encounter during the first 185 days of the measurement year.  Follow-up encounter is defined as the last encounter that is at least 30 days but no more than 180 after the initial encounter.

•  A Functional Status Assessment (FSA) is based on administration of a validated instrument to eligible patients that asks patients to answer questions related to various domains including: pain, physical function, emotional well-being, health-related quality of life, symptom acuity.

•  The FSA questionnaire must be present in the chart.  In order to indicate that it is present for calculation in the numerator, a valid LOINC code must be selected each time an FSA is completed.  This LOINC code must be linked to a procedure code (that is not the office code).  The procedure code will be office defined.  It must be indicated as a result in the procedure properties and tagged to the appropriate LOINC code.

• The MLHF and KCCQ Questionnaires are available as templates.  Please contact software support if they are not currently in your list of available templates.

•  The only data used to determine the denominator is data from the ChartMaker Clinical Module. If a patient encounter was not entered into the ChartMaker Clinical Module, that encounter is not included in the denominator for the statistical calculations on the Meaningful Use Dashboard. Please add these additional patients to the denominator and recalculate the percentage for Attestation purposes.