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  1. eCQM Issue Tracker
  2. CQM-5594

Documentation requirements for patient self-reported results

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Lauren Hill
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      ​Thank you for your inquiry about self reports for CMS125v11 Breast Cancer Screening. Self-reported mammography are acceptable to meet numerator criteria given they are performed within the required timeframe and documented using a code from the "Mammography value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018). Having a result from the mammogram is not a requirement to meeting numerator compliance, as expressed in the logic below.

      Numerator
      exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
      where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period",
      end of "Measurement Period"]))
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      ​Thank you for your inquiry about self reports for CMS125v11 Breast Cancer Screening. Self-reported mammography are acceptable to meet numerator criteria given they are performed within the required timeframe and documented using a code from the "Mammography value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018). Having a result from the mammogram is not a requirement to meeting numerator compliance, as expressed in the logic below. Numerator exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", end of "Measurement Period"]))
    • CMS0125v11
    • Understanding documentation requirements for patient self-reported results

      Background: In the eCQM specifications for Breast Cancer Screening (CMS125v10), the guidance states that "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." This seems to imply that patient self-reported results can be counted towards compliance.
       
      Question: Can patient self-reported results for mammograms be counted towards measure compliance? If so, in the event of an audit, what documentation is required to be present in the patient chart - (1) a simple text statement noting that the patient self-reported results for the mammogram within the compliance period, (2) evidence of the mammogram screening, (3) other details? 

            edave Mathematica EC eCQM Team
            laurenhill Lauren Hill (Inactive)
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