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  1. eCQM Issue Tracker
  2. CQM-6571

MIPS Once Per Year Measures - See CQM-6488

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Kaitlyn Nicole Faircloth
    • 5163703634
    • North American Partners in Anesthesia
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      Thank you for your question regarding CMS69v11 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. This measure requires that BMI is recorded once per patient during the measurement period. If more than one BMI is recorded during the measurement period, and any of the documented BMI assessments is outside of normal parameters, there must also be documentation of an appropriate follow-up plan during the measurement period for performance to be met for the measure. The timing of the numerator actions are not tied to the encounter, but must be completed during the measurement period.

      Thank you for your inquiry regarding the eCQM collection types of CMS139v11 Falls: Screening for Future Fall Risk and CMS138v11 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. These measures are patient-based measures, which evaluate the care of a patient and assign the patient to membership in one or more measure segments or populations (https://ecqi.healthit.gov/sites/default/files/eCQM-Logic-and-Guidance-v6.pdf#page=6). Per measure specifications, the initial population, denominator and numerator requirements are separate; to meet each criteria, you would need documentation of the required codes and timings for each.

      For CMS139v11, a patient 65 years or older meets initial population/denominator as long as there is one qualifying encounter during the measurement period, and meets numerator as long as there is one qualifying fall risk screening during the measurement period. The logic does not require the fall risk screening to be tied to the initial population/denominator encounter.

      CMS138v11 has three population criteria. Please refer to the measure specifications for each population criteria's requirements. For this measure, the logic also does not require the tobacco use screenings to be tied to the initial population encounter; when evaluating the tobacco use screening criteria, the measure considers the most recent tobacco use screening taken during the measurement period.

      For additional guidance on how to calculate these eCQMs, you may review the 2023 Performance Period eCQM workflow diagrams available on the eCQI Resource Center: https://ecqi.healthit.gov/sites/default/files/EC-eCQM-Flows-2022-v2.zip.

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      Thank you for your question regarding CMS69v11 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan. This measure requires that BMI is recorded once per patient during the measurement period. If more than one BMI is recorded during the measurement period, and any of the documented BMI assessments is outside of normal parameters, there must also be documentation of an appropriate follow-up plan during the measurement period for performance to be met for the measure. The timing of the numerator actions are not tied to the encounter, but must be completed during the measurement period. Thank you for your inquiry regarding the eCQM collection types of CMS139v11 Falls: Screening for Future Fall Risk and CMS138v11 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention. These measures are patient-based measures, which evaluate the care of a patient and assign the patient to membership in one or more measure segments or populations ( https://ecqi.healthit.gov/sites/default/files/eCQM-Logic-and-Guidance-v6.pdf#page=6 ). Per measure specifications, the initial population, denominator and numerator requirements are separate; to meet each criteria, you would need documentation of the required codes and timings for each. For CMS139v11, a patient 65 years or older meets initial population/denominator as long as there is one qualifying encounter during the measurement period, and meets numerator as long as there is one qualifying fall risk screening during the measurement period. The logic does not require the fall risk screening to be tied to the initial population/denominator encounter. CMS138v11 has three population criteria. Please refer to the measure specifications for each population criteria's requirements. For this measure, the logic also does not require the tobacco use screenings to be tied to the initial population encounter; when evaluating the tobacco use screening criteria, the measure considers the most recent tobacco use screening taken during the measurement period. For additional guidance on how to calculate these eCQMs, you may review the 2023 Performance Period eCQM workflow diagrams available on the eCQI Resource Center: https://ecqi.healthit.gov/sites/default/files/EC-eCQM-Flows-2022-v2.zip .
    • CMS0068v12, CMS0069v11, CMS0138v11, CMS0139v11
    • Affects Performance Rates for Eligible Clinicians

      Per the specifications for CMS139v11 (Falls: Screening for Future Risk), it states the Numerator is "Patients who were screened for future fall risk at least once within the measurement period".  With that being said, if the patient is screened at every encounter, will this metric include ALL screenings for ALL encounters for this patient during the performance year?  

       

      Per the specifications for CMS69v11 (Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan), it states the Numerator is "Patients with a documented BMI during the encounter or during the measurement period, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the measurement period" and under the Guidance section states "This eCQM is a patient-based measure. This measure is to be reported a minimum of once per reporting period for patients seen during the reporting period.".  With that being said, if the patient is screened at every encounter, will this metric include ALL screenings for ALL encounters for this patient during the performance year? 

       

      Per the specifications for CMS138v11 (Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention), the guidance section states "To satisfy the intent of this measure, a patient must have at least one tobacco use screening during the measurement period. If a patient has multiple tobacco use screenings during the measurement period, only the most recent screening, which has a documented status of tobacco user or tobacco non-user, will be used to satisfy the measure requirements."  Which I understand to mean the most recent encounter would be the submitted encounter for that patient if multiple encounters during the performance year.

       

      The response I received from the QPP regarding the CQM versions (MIPS 155 in lieu of CMS139v11) states "The submission frequency for all 3 measures is Patient-Process: measures are submitted a minimum of once per patient during the performance period. The most advantageous quality data code will be used if the measure is submitted more than once."  

       

      I want to verify that that would be the case with the eCQMs as well.

       

      Please also see ticket CQM-6488, as it was the original thread.

            edave Mathematica EC eCQM Team
            kfaircloth Kaitlyn Faircloth (Inactive)
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