To satisfy the measure requirement, there is no need to find the original procedure in the patient record. We just need documentation in medical record that the procedure was done. We will consider adding the a new line of logic for "communication: from patient to provider" during the next round of annual updates.

(Text also found in attachment) NCQA agrees that in most cases patient self-report is acceptable for quality measurement if the necessary information is present, including the date of service and if required, the result of the test or procedure. The minimum amount of information needed is enough information to ensure the service happened in the required time period. In some instances, the year provides enough information. In other instances, the date, month and year might be necessary. For example, a patient report stating the type of colorectal cancer screening, when it was performed (year) and the result or finding, can count towards the Colorectal Cancer Screening measure (CMS130) as long as it is documented in the patient’s medical record and meets the measure requirements (e.g., fecal occult blood test (FOBT) during the measurement period, flexible sigmoidoscopy during the measurement period or the four years prior to the measurement period, colonoscopy during the measurement period or the nine years prior to the measurement period). NCQA would like additional feedback on using patient self-report for procedures in the following measures: CMS ID Measure Name Procedures CMS153 Chlamydia Screening for Women Sexual Activity CMS124 Cervical Cancer Screening Pap Smear Hysterectomy CMS130 Colorectal Cancer Screening Colonoscopy Colectomy CMS125 Breast Cancer Screening Mastectomy Mammogram Specifically, we would like your input on: 1. Relying on patient self-report for the following procedures: Sexual Activity, Colonoscopy, Mammography, and Pap Smear. In particular, if this type of information is documented in the medical record at the level of detail required for the measure, do you agree it can be used to satisfy the measure? 2. The proposed logic that will be used in the eMeasures to specify these procedures. As an example, to indicate a pap smear that a patient reported to a provider, we will include the following statement in CMS124 (Cervical Cancer Screening):  OR: "Laboratory Test, performed: Pap Test (result)" < 3 year(s) ends before end of "Measurement Period"  OR:  AND: Age>= 30 year(s) at: "Occurrence A of Laboratory Test, Performed: Pap Test"  AND: "Occurrence A of Laboratory Test, Performed: Pap Test" satisfies all:  (result) < 5 year(s) ends before end of "Measurement Period"  satisfies any:  <= 1 day(s) starts after or concurrent with start of "Laboratory Test, Performed: HPV Test (result)"  <= 1 day(s) starts before start of "Laboratory Test, Performed: HPV Test (result)"  OR: “Communication: From Patient to Provider: Previous Receipt of Pap Smear” < 3year(s) ends before end of “Measurement Period” For sexual activity, the logic statement would be: o AND:  OR: Union of:  "Diagnosis: Other Female Reproductive Conditions"  "Diagnosis: Genital Herpes"  "Diagnosis: Gonococcal Infections and Venereal Diseases"  "Medication, Active: Contraceptive Medications"  "Diagnosis: Inflammatory Diseases of Female Reproductive Organs"  "Diagnosis: Chlamydia"  "Diagnosis: HIV"  "Diagnosis: Syphilis"  "Diagnosis: Complications of Pregnancy, Childbirth and the Puerperium"  overlaps "Measurement Period"  OR: Union of:  "Laboratory Test, Order: Pregnancy Test"  "Laboratory Test, Order: Pap Test"  "Procedure, Performed: Delivery Live Births"  "Laboratory Test, Order: Lab Tests During Pregnancy"  "Laboratory Test, Order: Lab Tests for Sexually Transmitted Infections"  "Medication, Order: Contraceptive Medications"  "Diagnostic Study, Order: Diagnostic Studies During Pregnancy"  "Procedure, Performed: Procedures During Pregnancy"  "Procedure, Performed: Procedures Involving Contraceptive Devices"  during "Measurement Period"  OR: “Risk Category Assessment: Sexually Activity“ during “Measurement Period”

Based on the CRP recommendations, we will update the guidance as follows: "Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1 . Patient self-report is not allowed for laboratory tests."