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  1. eCQM Issue Tracker
  2. CQM-2202

Additional feedback on incorporating patient self-report for surgical procedures

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Done
    • Icon: Minor Minor
    • Measure
    • As recommended by the CRP, we will keep procedure performed in the measure logic. We will add guidance to indicate self-reported procedures can be reported as procedures that have been performed. This change will be made during the 2017 update cycle
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      NCQA would like additional feedback on incorporating patient self-report for surgical procedures into certain eMeasures. In particular, we think that for the following procedure and measure combinations, the procedure performed template should be used for reporting patient self-reported services and we will NOT be adding a patient-provider communication element to the measure to capture this data.

      CMS ID Measure Name Surgical Procedures
      CMS124 Cervical Cancer Screening Hysterectomy
      CMS130 Colorectal Cancer Screening Colectomy
      CMS125 Breast Cancer Screening Mastectomy
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      NCQA would like additional feedback on incorporating patient self-report for surgical procedures into certain eMeasures. In particular, we think that for the following procedure and measure combinations, the procedure performed template should be used for reporting patient self-reported services and we will NOT be adding a patient-provider communication element to the measure to capture this data. CMS ID Measure Name Surgical Procedures CMS124 Cervical Cancer Screening Hysterectomy CMS130 Colorectal Cancer Screening Colectomy CMS125 Breast Cancer Screening Mastectomy
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      Please provide your vote by leaving a comment indicating "Yes" or "No."

      • Vote ‘Yes’ if you agree the procedure performed template is appropriate and sufficient to report patient self-reported procedures.

      • Vote ‘No’ if you would like to see the measure contain the patient-provider communication template for reporting patient self-report procedures.
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      Please provide your vote by leaving a comment indicating "Yes" or "No." • Vote ‘Yes’ if you agree the procedure performed template is appropriate and sufficient to report patient self-reported procedures. • Vote ‘No’ if you would like to see the measure contain the patient-provider communication template for reporting patient self-report procedures.
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      Yes: 9/9 (100%)

      No: 0/9 (0%)
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      Yes: 9/9 (100%) No: 0/9 (0%)

      Sometimes when a clinician is taking a patient history, the patient will report procedures that have been performed in the past. Those procedures should be able to count as exclusions as long as the minimum amount of information needed to ensure the service happened in the required time period is present. In some instances, the year provides enough information. In other instances, the date, month and year might be necessary.

      There have been some requests to include a patient provider communication variable in several eMeasures to capture these interactions. But in many EHRs data about surgical procedures from any source are captured in the same way. Therefore, these services can be reported on a Procedure Performed template.

            edave Mathematica EC eCQM Team
            JLeflore Mathematica EH eCQM Team
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