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  2. CQM-5941

Difference in calculation/attribution between INDV and Group reporting for CMS 165 v10

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    • Icon: EC eCQMs EC eCQMs
    • Resolution: Answered
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    • Jill Meredith
    • 513-722-6042
    • NextGen Healthcare
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      Thank you for your inquiry regarding the 2022 and 2023 performance period versions of CMS165v11 Controlling High Blood Pressure. The answer is provided to clarify the measure's CQL specification and expected calculation. For questions related to program reporting requirements (e.g., individual or group participation), please submit a ticket to the QPP Service Center.

      To clarify, the blood pressure reading in the numerator does not need to be associated with the qualifying encounter in the denominator. Therefore, if provider A, B and C see the same patient and have a shared EHR, and that the patient's most recent qualifying blood pressure recorded in EHR is controlled within range, the patient is expected to be included in the numerator for all three providers. Conversely, if the patient's most recent qualifying blood pressure is not controlled within range, the patient should not be included in the numerator for all three providers.

      Using your example, assuming the patient has two blood pressure readings that qualify for the numerator in 2022, and assuming the readings are recorded on the same day as the visits and dated accordingly (i.e.., 11/01/2022, 12/06/2022), the most recent blood pressure reading for the patient is the 12/06/2022 record with the 112/68 reading. Assuming that all three providers see the patient during 2022 (meeting denominator encounter visit requirement) and have shared EHR records, the patient is expected to meet the numerator for all three providers. Hope this helps.
      Show
      Thank you for your inquiry regarding the 2022 and 2023 performance period versions of CMS165v11 Controlling High Blood Pressure. The answer is provided to clarify the measure's CQL specification and expected calculation. For questions related to program reporting requirements (e.g., individual or group participation), please submit a ticket to the QPP Service Center. To clarify, the blood pressure reading in the numerator does not need to be associated with the qualifying encounter in the denominator. Therefore, if provider A, B and C see the same patient and have a shared EHR, and that the patient's most recent qualifying blood pressure recorded in EHR is controlled within range, the patient is expected to be included in the numerator for all three providers. Conversely, if the patient's most recent qualifying blood pressure is not controlled within range, the patient should not be included in the numerator for all three providers. Using your example, assuming the patient has two blood pressure readings that qualify for the numerator in 2022, and assuming the readings are recorded on the same day as the visits and dated accordingly (i.e.., 11/01/2022, 12/06/2022), the most recent blood pressure reading for the patient is the 12/06/2022 record with the 112/68 reading. Assuming that all three providers see the patient during 2022 (meeting denominator encounter visit requirement) and have shared EHR records, the patient is expected to meet the numerator for all three providers. Hope this helps.
    • CMS0165v11
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      For patient level measures, if the calculation is exactly the same when reporting as an Individual as it is when reporting as a group, there is no incentive for a Individual provider to own their patient's outcomes when reporting as an Individual. It is confusing to clients when there is no clear distinction between the attribution methodologies.
      Show
      For patient level measures, if the calculation is exactly the same when reporting as an Individual as it is when reporting as a group, there is no incentive for a Individual provider to own their patient's outcomes when reporting as an Individual. It is confusing to clients when there is no clear distinction between the attribution methodologies.

      We have a client who is reporting as an Individual who is questioning the logic in the measure as calculated. The practice is reporting both as a Group and for selected Individual Providers and the INDV logic differs slightly from the Group logic

      The scenario is as follows:

      Provider A saw the patient at the practice on 10/17/2022  BP was 160/90. Provider prescribed a BP med and follow up visit. Patient’s BP was out of range
      Provider B saw the patient at the practice on 11/01/2022  BP was 92/62. Patient’s BP was in range.
      Provider C saw the patient at the practice on 12/06/2022  BP was 112/68. Patient’s BP was in range.

      •    The patient is showing as Performance Met in the Group calculation at the TIN level and for Provider B and Provider C at the Individual calculation level and is appearing in the NUM for those scenarios.
      •    The patient is showing as Performance NOT Met in the Individual calculation for Provider A and does not appear in the NUM for Provider A.

      The most recent BP for the patient at the practice was on 12/06/2022 and it was normal so the patient is meeting at the Group level and for both Provider B and C who both recorded controlled BP readings. 

      The last BP considered in the Individual calculation for Provider A, which is only looking at the encounters in the DEN in which that provider saw the patient, is looking at the BP of 160/90 as the most recent BP reading for that patient.

      1.    Should the Individual calculation be looking at the most recent encounter even if it occurred AFTER the last encounter in which that provider saw the patient? 
      2.    Should Provider A be meeting the measure as Performance Met, even though the most recent BP in the chart happened 2 months after the last time the provider saw the patient and did not occur in a DEN encounter performed by Provider A? 
      3.    Conversely, if the patient was normal when the provider saw the patient, but the most recent BP that happened 2 months after the Individual provider saw the patient was found to be out of range, should that patient not meet the measure for the Individual Provider?

      Thank you for helping us clarify the logic calculation for our client. The dropdown will not allow me to select the 2022 version of the measure, so I selected the 2023 version, but the question is about both.

            edave Mathematica EC eCQM Team
            jillmeredith Jill Meredith (Inactive)
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