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  1. eCQM Issue Tracker
  2. CQM-4716

Clarification in Numerator requirement for CMS69v9 (CMS statement Vs CQL)

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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      ​Thank you for your inquiry about CMS69v9: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. We are aware that a discrepancy exists between the numerator statement provided in the header and the CQL. Since the header is only meant to provide a written narrative of the measure logic, please refer to the measure logic itself as the source of truth regarding the numerator. Therefore, in order to meet the measure numerator, the most recent documented BMI can occur during the qualifying encounter or within the previous 12 months of the qualifying encounter. However, the follow-up plan/intervention must be documented during the qualifying encounter or within 12 months after the most recent documented BMI.

      We are aware that that issue carries over to the PY2022 specification. Unfortunately, we are not able to update the information on the CMS page at this time. However, we will work to align the measure header and logic during the upcoming update cycle for the PY2023 specification.
      Show
      ​Thank you for your inquiry about CMS69v9: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. We are aware that a discrepancy exists between the numerator statement provided in the header and the CQL. Since the header is only meant to provide a written narrative of the measure logic, please refer to the measure logic itself as the source of truth regarding the numerator. Therefore, in order to meet the measure numerator, the most recent documented BMI can occur during the qualifying encounter or within the previous 12 months of the qualifying encounter. However, the follow-up plan/intervention must be documented during the qualifying encounter or within 12 months after the most recent documented BMI. We are aware that that issue carries over to the PY2022 specification. Unfortunately, we are not able to update the information on the CMS page at this time. However, we will work to align the measure header and logic during the upcoming update cycle for the PY2023 specification.
    • CMS0069v10
    • CMS69v9/NQFna
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      Hi Team,
      We need a clarification regarding the CMS69v9 Numerator support.
      We as a vendor have supported the measure using the CQL logic provided by CMS.
      https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS69v9.html

      High BMI and Order for Follow Up
      "Most Recent Documented BMI" MostRecentBMI
        with ( ( ( ["Intervention, Order": "Follow Up for Above Normal BMI"]
            union ["Intervention, Order": "Referrals Where Weight Assessment May Occur"] ) ReferralHighBMI
            where ReferralHighBMI.reason in "Overweight or Obese"
        )
          union ["Medication, Order": "Medications for Above Normal BMI"] ) HighBMIIntervention
          such that MostRecentBMI.relevantDatetime 12 months or less on or before day of HighBMIIntervention.authorDatetime
        where MostRecentBMI.result >= 25 'kg/m2'

      But the clients (providers) are accessing the CMS statement in general for understanding. The Numerator criteria statement provided differs from the CQL provided information.
      Ref: https://ecqi.healthit.gov/ecqm/ep/2021/cms069v9

      The statement states - "Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter"

      Please provide more insights on the below 2 asks.
      1. Can the CMS clarify whether the CQL provided information is to be supported in the measure for 2021 submission?
      2. If so, then the general information provided can be updated in CMS page?

      NOTE:
      1. The ticket has been designated as CRITICAL because we have escalated queries from clients.
      2. I have enclosed appropriate screen shots for the reference.
      3. The same issue is applicable for CMS69v10 for 2022 measurement period.
      https://ecqi.healthit.gov/ecqm/ep/2022/cms069v10
      https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS69v10.html
      Show
      Hi Team, We need a clarification regarding the CMS69v9 Numerator support. We as a vendor have supported the measure using the CQL logic provided by CMS. https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS69v9.html High BMI and Order for Follow Up "Most Recent Documented BMI" MostRecentBMI   with ( ( ( ["Intervention, Order": "Follow Up for Above Normal BMI"]       union ["Intervention, Order": "Referrals Where Weight Assessment May Occur"] ) ReferralHighBMI       where ReferralHighBMI.reason in "Overweight or Obese"   )     union ["Medication, Order": "Medications for Above Normal BMI"] ) HighBMIIntervention     such that MostRecentBMI.relevantDatetime 12 months or less on or before day of HighBMIIntervention.authorDatetime   where MostRecentBMI.result >= 25 'kg/m2' But the clients (providers) are accessing the CMS statement in general for understanding. The Numerator criteria statement provided differs from the CQL provided information. Ref: https://ecqi.healthit.gov/ecqm/ep/2021/cms069v9 The statement states - "Patients with a documented BMI during the encounter or during the previous twelve months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter" Please provide more insights on the below 2 asks. 1. Can the CMS clarify whether the CQL provided information is to be supported in the measure for 2021 submission? 2. If so, then the general information provided can be updated in CMS page? NOTE: 1. The ticket has been designated as CRITICAL because we have escalated queries from clients. 2. I have enclosed appropriate screen shots for the reference. 3. The same issue is applicable for CMS69v10 for 2022 measurement period. https://ecqi.healthit.gov/ecqm/ep/2022/cms069v10 https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS69v10.html

      1. CMS page Information 1.png
        CMS page Information 1.png
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      2. CMS page Information 2.png
        CMS page Information 2.png
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      3. CQL general Info 1.png
        CQL general Info 1.png
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      4. CQL general Info 2.png
        CQL general Info 2.png
        41 kB
      5. CQL screenshot 1.png
        CQL screenshot 1.png
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      6. CQL screenshot 2.png
        CQL screenshot 2.png
        152 kB

          edave Mathematica EC eCQM Team
          ranesh Anesh Ramadhas (Inactive)
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