CMS-10210 THA/TKA Patient-Reported Outcome-based Performance Measu

Hospital Inpatient Quality Reporting Program
THA/TKA Patient-Reported Outcome-based Performance Measure
Please Note: A data collection tool available within the Hospital Quality Reporting system via the Hospital
Quality Reporting Secure Portal allows hospitals to complete and submit their THA/TKA PRO-PM data.
This document is a representation of the text contained in the measure data form and is for reference
purposes only.

Hospital Inpatient Quality Reporting Program
THA/TKA Patient-Reported Outcome-based Performance Measure

Hospital Inpatient Quality Reporting Program
THA/TKA Patient-Reported Outcome-based Performance Measure

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of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 09381022 (Expires XX/XX/XXXX). The time required to complete this information collection is estimated to average 10 minutes per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, MD 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or
any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to
submit your documents, please contact the Inpatient Value, Incentives, and Quality Reporting Outreach and Education
Support Contractor at (844) 472-4477.