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  1. eCQM Issue Tracker
  2. CQM-5948

PY 2023 eCQMs: Clarification of patient self-reporting measures

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Gail Henson-Swaney
    • 713-798-1132
    • Baylor College of Medicine
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      ​​Thank you for your inquiry about patient self-reporting on CMS125, Breast Cancer Screening. Self-reported services may be acceptable given that they are performed within the required timeframe, documented using a code from the appropriate value set, and documented in a structured field in the EHR, approved for entry by a physician for the management of care.
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      ​​Thank you for your inquiry about patient self-reporting on CMS125, Breast Cancer Screening. Self-reported services may be acceptable given that they are performed within the required timeframe, documented using a code from the appropriate value set, and documented in a structured field in the EHR, approved for entry by a physician for the management of care.
    • CMS0125v11
    • Accurate reporting

      We would like to get some clarification for inclusion of patient self-reporting of specific procedures to be counted in the measure numerator.

      There are some measures, such as CMS 147, 125, and 130 which previously included wording in the Guidance section of the eCQMs which referenced patient self-report and we see that for PY 2023 this wording has been removed. Does this mean that patient reported is no longer allowed?

      As an example, please see below for screenshots of the specific Guidance for CMS 125 as it changed from PY 2022 to PY 2023.

      We note that the technical release notes for 2023 give the reason for the wording change as follows:

      In plain terms, can a patient reported mammogram be used to satisfy the numerator for CMS125, and can you please advise the complete list of eCQMS for which a patient reported performance of the numerator action is acceptable to meet the measure?

       

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            edave Mathematica EC eCQM Team
            hensonsw@bcm.edu Gail Henson-Swaney (Inactive)
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