When we’re reviewing your clinicians’ data, it may be helpful to know what we are looking for in order for us to verify to CMS that your data is accurate and complete. Measure 353 requires documentation that the implanted prosthesis is identified in the operative report.
This documentation may be found in the patient’s medical record or operative notes. The relevant document should be made available to the auditor for the patient requested.
What needs to be included?
This measure requires that the prosthetic implant specifications be included in the operative report. Specifications include:
- Implant manufacturer
- Brand name of the implant
- Size of each implant
How frequently should this measure be reported?
This measure is to be submitted each time a procedure for total knee replacement is performed on a patient during the performance period.