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  2. CQM-6006

Hospice and deceased during measurement period

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Leslie Calihman Alabi
    • 919-660-0557
    • Duke Connected Care
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      ​​Thank you for your inquiry regarding CMS2v12: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. For the eCQM, patients who had hospice care and deceased patients are not excluded from the measure denominator. Per the eCQM measure specifications available on the eCQI resource center (https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v12.html ), only patients that have been diagnosed with depression or bipolar disorder, as defined within the codes of the "Bipolar Diagnosis" (2.16.840.1.113883.3.600.450) and "Depression Diagnosis" (2.16.840.1.113883.3.600.145) value sets, are captured as denominator exclusions. You can review codes included in each value set on the Value Set Authority Center (VSAC) website at https://vsac.nlm.nih.gov.

      For CMS122v11: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) and CMS165v11: Controlling High Blood Pressure are specified to exclude patients (from the denominator) who are in hospice care for any part of the measurement period. Neither measure is specified to capture and exclude patients who are deceased during the measurement period.
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      ​​Thank you for your inquiry regarding CMS2v12: Preventive Care and Screening: Screening for Depression and Follow-Up Plan. For the eCQM, patients who had hospice care and deceased patients are not excluded from the measure denominator. Per the eCQM measure specifications available on the eCQI resource center ( https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS2v12.html ), only patients that have been diagnosed with depression or bipolar disorder, as defined within the codes of the "Bipolar Diagnosis" (2.16.840.1.113883.3.600.450) and "Depression Diagnosis" (2.16.840.1.113883.3.600.145) value sets, are captured as denominator exclusions. You can review codes included in each value set on the Value Set Authority Center (VSAC) website at https://vsac.nlm.nih.gov . For CMS122v11: Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%) and CMS165v11: Controlling High Blood Pressure are specified to exclude patients (from the denominator) who are in hospice care for any part of the measurement period. Neither measure is specified to capture and exclude patients who are deceased during the measurement period.
    • CMS0002v12, CMS0122v11
    • 1000s of patients each reporting period

      Since the inception of MSSP reporting (via Web Interface and previous portals), if a patient had hospice care or deceased during the measurement period, they were to be marked as not qualified for the sample.  We were required to report on their status (hospice and start date, or deceased and date of death). Are hospice patients and deceased patients disqualified from the sample in eCQM reporting as well, assuming dates correspond with the measurement year? While this question does not pertain to specific measures, as an MSSP ACO, we will be reporting on CMS-2, CMS-122, and CMS-165.  Thank you

            edave Mathematica EC eCQM Team
            lcalabi Leslie Alabi
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