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  1. eCQM Issue Tracker
  2. CQM-4900

Remove QRDA-1 guidance statements

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Details

    • EP/EC eCQMs
    • Status: Open
    • Moderate
    • Resolution: Unresolved
    • None

    Description

      Brief Description of Measure:

      ​CMS124: Cervical Cancer Screening:
      Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria:

      • Women age 21-64 who had cervical cytology performed within the last 3 years
      • Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years
        CMS125: Breast Cancer Screening:
        Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period
        CMS127: Pneumococcal Vaccination Status for Older Adults:
        Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine
        CMS130: Colorectal Cancer Screening:
        Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer
        CMS147: Preventive Care and Screening: Influenza Immunization:
        Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization
        CMS153: Chlamydia Screening for Women
        Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period

      Description of Issue:

      ​Some eCQMs include QRDA-1 reporting guidance in the header. CMS publishes QRDA-1 Implementation Guides (e.g. 2022 CMS Quality Reporting Document Architecture (QRDA) Category I Implementation Guide (IG) (https://ecqi.healthit.gov/sites/default/files/QRDA-HQR-2022-CMS-IG-508.pdf)), which should serve as the primary guidance and source of truth. 
      To avoid redundancy, we propose removing QRDA-1 statements from the headers.

      Proposed Solution:

      ​Below are statements that we propose to remove from the measures:

      CMS124
      "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."
      CMS125
      "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."

      CMS127
      Patient self-report for procedures as well as immunizations should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1.

      CMS130
      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.

      CMS147
      Patient self-report for procedures as well as immunizations should be recorded in 'Procedure, Performed' template or 'Immunization, Administered' template in QRDA-1.

      CMS153
      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.

      Rationale for Change:

      This change will remove redundant guidance from measure headers and avoid redundancy with existing guides published to aid implementation. ** 

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            khancock Mathematica EC eCQM Team
            sgearhart Mathematica EH eCQM Team
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            Dates

              Created:
              Updated: