Brief Description of Measure:
​CMS249: Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture:
Percentage of female patients 50 to 64 years of age without select risk factors for osteoporotic fracture who received an order for a dual-energy x-ray absorptiometry (DXA) scan during the measurement period

Description of Issue:
​The current specification excludes any qualifying diagnosis that occurs any time before the end of the "Measurement Period" (i.e., any time in history through 12/31 11:58PM). However, this timing does not does not exclude qualifying diagnoses that occur during the last minute of the measurement period (i.e., 12/31 11:59PM). 
The measure developer proposes to revise the logic from "starts before end..." to "starts on or before day of end of..." to improve the timing precision and further align with the measure intent of excluding qualifying diagnoses any time on or before the end of the measurement period, including 12/31 11:59PM.

Proposed Solution:
​//Before
define "Has Independent Risk Factors Applicable Any Time":
  exists ( ["Diagnosis": "Type 1 Diabetes"]
    union ["Diagnosis": "End Stage Renal Disease"]
    union ["Diagnosis": "Osteogenesis Imperfecta"]
    union ["Diagnosis": "Ankylosing Spondylitis"]
    union ["Diagnosis": "Psoriatic Arthritis"]
    union ["Diagnosis": "Ehlers Danlos Syndrome"]
    union ["Diagnosis": "Cushings Syndrome"]
    union ["Diagnosis": "Marfan's Syndrome"]
    union ["Diagnosis": "Hyperparathyroidism"]
    union ["Diagnosis": "Lupus"] ) IndependentRiskDiagnosis
    where IndependentRiskDiagnosis.prevalencePeriod starts before
    end "Measurement Period"

//After
... exists ( "DiagnosisInPatientHistory"(  ...
          union ["Diagnosis": "Type 1 Diabetes"]
          union ["Diagnosis": "End Stage Renal Disease"]
          union ["Diagnosis": "Osteogenesis Imperfecta"]
          union ["Diagnosis": "Ankylosing Spondylitis"]
          union ["Diagnosis": "Psoriatic Arthritis"]
          union ["Diagnosis": "Ehlers Danlos Syndrome"]
          union ["Diagnosis": "Cushings Syndrome"]
          union ["Diagnosis": "Hyperparathyroidism"]
          union ["Diagnosis": "Marfan's Syndrome"]
          union ["Diagnosis": "Lupus"] ...
      ))

define function "DiagnosisInPatientHistory"(Diagnosis List<"Diagnosis"> ):
  Diagnosis Dx
    where Dx.prevalencePeriod starts on or before day of
    end of "Measurement Period"

Rationale for Change:
The measure developer proposes to revise the logic to increase alignment with the measure intent of excluding qualifying diagnoses any time on or before the end of the measurement period. This change will also increase the precision of the measure's timing.