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  1. eCQM Issue Tracker
  2. CQM-6105

Need Clarification on Numerator on CMS125v11, CMS124v11 and CMS130v11

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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      ​Thank you for your inquiry about CMS125v11, CMS124v11, and CMS130v11. Please note that although guidance was removed in regards to self-reporting, all three of these measures allow for self report. Self-reported screenings may count towards the numerator when performed within the measurement period and/or within the time frame indicated. Self-reported screenings are accepted if the information is documented in a structured field in the EHR, approved for entry by the provider. Please see details below regarding documentation required of the reporting provider to meet each measure's numerator requirements.

      For CMS125v11, applicable mammograms may count towards the numerator criteria given that they are performed within the required time frame and documented via QDM datatype "Diagnostic Study, Performed" using a code from the "Mammography" value set (2.16.840.1.113883.3.464.1003.108.12.1018). A result is not required.

      For CMS124v11, applicable screenings to meet the numerator criteria may include a cervical cytology or an HPV test. The applicable screenings mentioned above may count towards the numerator when performed within the required time frame and documented via QDM datatype "Laboratory Test, Performed" using a code from the "Pap Test" value set (2.16.840.1.113883.3.464.1003.108.12.1017) or "HPV Test" value set (2.16.840.1.113883.3.464.1003.110.12.1059). A "non-null" result is required using QDM attribute "result". A non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required.

      For CMS130v11, applicable screenings to meet the numerator criteria may include fecal occult blood test, FIT-DNA test, flexible sigmoidoscopy, CT colonography, or a colonoscopy. The applicable screenings mentioned above may count towards the numerator when performed within the required timeframe and documented via QDM datatypes and codes below. A result is not required for the flexible sigmoidoscopy, colonoscopy, or CT colonography to be numerator compliance. A "non-null" result is required using the QDM attribute "result" for screening options such as FOBT and FIT-DNA laboratory tests. A non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required.
      - "Laboratory Test, Performed: Fecal Occult Blood Test (FOBT)" using a code from "Fecal Occult Blood Test (FOBT)" value set (2.16.840.1.113883.3.464.1003.198.12.1011)"
      - "Laboratory Test, Performed: FIT DNA" using a code from "FIT DNA" value set (2.16.840.1.113883.3.464.1003.108.12.1039)
      - "Procedure, Performed: Flexible Sigmoidoscopy" using a code from "Flexible Sigmoidoscopy" value set (2.16.840.1.113883.3.464.1003.198.12.1010)
      - "Diagnostic Study, Performed: CT Colonography" using a code from "CT Colonography" value set (2.16.840.1.113883.3.464.1003.108.12.1038)
      - "Procedure, Performed: Colonoscopy" using a code from "Colonoscopy" value set (2.16.840.1.113883.3.464.1003.108.12.1020)

      For additional guidance on reading/reporting eCQM specifications, please refer to the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=0.
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      ​Thank you for your inquiry about CMS125v11, CMS124v11, and CMS130v11. Please note that although guidance was removed in regards to self-reporting, all three of these measures allow for self report. Self-reported screenings may count towards the numerator when performed within the measurement period and/or within the time frame indicated. Self-reported screenings are accepted if the information is documented in a structured field in the EHR, approved for entry by the provider. Please see details below regarding documentation required of the reporting provider to meet each measure's numerator requirements. For CMS125v11, applicable mammograms may count towards the numerator criteria given that they are performed within the required time frame and documented via QDM datatype "Diagnostic Study, Performed" using a code from the "Mammography" value set (2.16.840.1.113883.3.464.1003.108.12.1018). A result is not required. For CMS124v11, applicable screenings to meet the numerator criteria may include a cervical cytology or an HPV test. The applicable screenings mentioned above may count towards the numerator when performed within the required time frame and documented via QDM datatype "Laboratory Test, Performed" using a code from the "Pap Test" value set (2.16.840.1.113883.3.464.1003.108.12.1017) or "HPV Test" value set (2.16.840.1.113883.3.464.1003.110.12.1059). A "non-null" result is required using QDM attribute "result". A non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required. For CMS130v11, applicable screenings to meet the numerator criteria may include fecal occult blood test, FIT-DNA test, flexible sigmoidoscopy, CT colonography, or a colonoscopy. The applicable screenings mentioned above may count towards the numerator when performed within the required timeframe and documented via QDM datatypes and codes below. A result is not required for the flexible sigmoidoscopy, colonoscopy, or CT colonography to be numerator compliance. A "non-null" result is required using the QDM attribute "result" for screening options such as FOBT and FIT-DNA laboratory tests. A non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required. - "Laboratory Test, Performed: Fecal Occult Blood Test (FOBT)" using a code from "Fecal Occult Blood Test (FOBT)" value set (2.16.840.1.113883.3.464.1003.198.12.1011)" - "Laboratory Test, Performed: FIT DNA" using a code from "FIT DNA" value set (2.16.840.1.113883.3.464.1003.108.12.1039) - "Procedure, Performed: Flexible Sigmoidoscopy" using a code from "Flexible Sigmoidoscopy" value set (2.16.840.1.113883.3.464.1003.198.12.1010) - "Diagnostic Study, Performed: CT Colonography" using a code from "CT Colonography" value set (2.16.840.1.113883.3.464.1003.108.12.1038) - "Procedure, Performed: Colonoscopy" using a code from "Colonoscopy" value set (2.16.840.1.113883.3.464.1003.108.12.1020) For additional guidance on reading/reporting eCQM specifications, please refer to the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=0 .
    • CMS0124v11, CMS0125v11, CMS0130v11
    • Need to be able to provide complete accurate workflows to our Providers.

      For the eCQMs below does the Provider need to order the test to receive credit or only receive the result to get credit such as from a referring Provider. Example:  Would a Provider get credit for CMS130v11 if the Provider referred to a Gastroenterologist to perform a colonoscopy and received the report back.

       

      CMS125v11 Breast Cancer Screening

      CMS130v11 Colorectal Cancer Screening

      CMS124v11 Cervical Cancer Screening.

       

      These measures are no longer self-report by the patient. Also, for any of the measures that contain a lookback period prior to this year Patient self-report was allowed and so how will they get credit for this.

       

      We are trying to ensure that our Providers are documenting correctly and if they need both the order and the result in their charting.

            edave Mathematica EC eCQM Team
            kball Kimberly Ball (Inactive)
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