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  1. eCQM Issue Tracker
  2. CQM-2204

Additional feedback on incorporating patient self-report for diagnostic studies

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Done
    • Icon: Minor Minor
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    • ​As recommended by the CRP, we will keep diagnostic study performed in the measure logic. We will add guidance to indicate self-reported diagnostic studies can be reported as studies that have been performed.
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      NCQA would like additional feedback on incorporating patient self-report for diagnostic studies into certain eMeasures. In particular, we think that for the following diagnostic study and measure combinations, the procedure performed or diagnostic study 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 Diagnostic Study
      CMS124 Cervical Cancer Screening Pap Smear
      CMS130 Colorectal Cancer Screening Colonoscopy, Flexible SIgmoindoscopy
      CMS125 Breast Cancer Screening Mammogram
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      NCQA would like additional feedback on incorporating patient self-report for diagnostic studies into certain eMeasures. In particular, we think that for the following diagnostic study and measure combinations, the procedure performed or diagnostic study 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 Diagnostic Study CMS124 Cervical Cancer Screening Pap Smear CMS130 Colorectal Cancer Screening Colonoscopy, Flexible SIgmoindoscopy CMS125 Breast Cancer Screening Mammogram
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      Please provide your vote by leaving a comment indicating "Yes" or "No."

      • Vote ‘Yes’ if you agree the procedure/diagnostic study performed template is appropriate and sufficient to report patient self-reported procedures and diagnostic studies.
      • 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/diagnostic study performed template is appropriate and sufficient to report patient self-reported procedures and diagnostic studies. • 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: 6/8 (75%)

      No: 2/8 (25%)
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      Yes: 6/8 (75%) No: 2/8 (25%)

      Sometimes when a clinician is taking a patient history, the patient will report diagnostic studies 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. For example, a patient reporting 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).
      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 procedures or diagnostic studies from any source are captured in the same way. Therefore, these services can be reported on a Procedure Performed or Diagnostic Study Performed template.

            edave Mathematica EC eCQM Team
            JLeflore Mathematica EH eCQM Team
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