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  1. eCQM Issue Tracker
  2. CQM-1562

CMS124v4, CMS130v4 may have temporal logic inconsistent with their intent in header descriptions and previous version

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    • Resolution: Answered
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      The logic for each measure expresses the same time period as noted in the header. See explanation by measure.

      CMS124v4

      Ends before end of “Measurement Period’ includes the measurement period and the 2 years prior. For example if the measurement period is 2015, then the calculation for an event in 2013 would be:

      2015 – 2013 = 2

      Dates between 1/1/2013 and 12/31/2015 would apply to the numerator and that is what we would expect based on the numerator statement.

      The same calculation would apply to CMS130, which is also in years.

      These calculations are defined in Logic Guidance document from the CMS website (2014 eCQM Measure Logic Guidance v1.10 Update May 2015, page 36).


      CMS125v4

      In this example we want to capture a mammogram that takes place up to 24 months before the MP (January 1, 24 months prior to the MP through 12/31/MP).

      The calculation for a mammogram 1/1/2014 (the year before the measurement period of 2015) would be:
      (2015 – 2014)*12 + (12-1) = 12 + 11 = 23 months
      The calculation counts the last month of the measurement period as month 0.
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      The logic for each measure expresses the same time period as noted in the header. See explanation by measure. CMS124v4 Ends before end of “Measurement Period’ includes the measurement period and the 2 years prior. For example if the measurement period is 2015, then the calculation for an event in 2013 would be: 2015 – 2013 = 2 Dates between 1/1/2013 and 12/31/2015 would apply to the numerator and that is what we would expect based on the numerator statement. The same calculation would apply to CMS130, which is also in years. These calculations are defined in Logic Guidance document from the CMS website (2014 eCQM Measure Logic Guidance v1.10 Update May 2015, page 36). CMS125v4 In this example we want to capture a mammogram that takes place up to 24 months before the MP (January 1, 24 months prior to the MP through 12/31/MP). The calculation for a mammogram 1/1/2014 (the year before the measurement period of 2015) would be: (2015 – 2014)*12 + (12-1) = 12 + 11 = 23 months The calculation counts the last month of the measurement period as month 0.
    • CMS124v3/NQF0032, CMS125v3/NQFna, CMS130v3/NQF0034
    • CMS125v3

      CMS124v4, CMS125v4, CMS130v4 have been transistioned to new QDM syntax. The transition may have introduced inconsistencies in temporal logic from 'ends before or during' to 'ends before or end'.

      (Please also read the comment with updated information.)

      CMS124 for example,

      In header (v3 & v4 are the same)
      Numerator
      Women with one or more Pap tests during the measurement period or the two years prior to the measurement period

      Population criteria
      CMS124v3
      Numerator =
      AND: "Laboratory Test, Result: Pap Test (result)" <= 2 year(s) ends before or during "Measurement Period"

      CMS124v4
      Numerator =
      AND: "Laboratory Test, Performed: Pap Test (result)" <= 2 year(s) ends before end of "Measurement Period"

      The semantic seems different from v3 to v4. The same situation applies to CMS125 and CMS130. In CMS125, there is a change of the time interval, which makes more sense.

      CMS125v3
      Numerator =
      AND: "Diagnostic Study, Result: Mammogram (result)" <= 12 month(s) ends before or during "Measurement Period"

      CMS125v4
      Numerator =
      AND: "Diagnostic Study, Performed: Mammogram" < 24 month(s) ends before end of "Measurement Period"

      In CMS124 and CMS130, the time intervals are the same with the previous version, which could be wrong. Please review and provide guidance.

            edave Mathematica EC eCQM Team
            jfflin Jeffrey Lin (Inactive)
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