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  1. eCQM Issue Tracker
  2. CQM-6649

CMS 125v11 and v12. Are self reported mammograms allowed for this?

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Susan Mayhall
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      Thank you for your inquiry about self reports for CMS125v11 and CMS125v12, Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. Self-reported mammography is an acceptable criterion for this measure given the mammogram is performed within the required timeframe and documented using a code from the "Mammography value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018). Having a result from the mammogram is not a requirement to meeting numerator compliance, as expressed in the logic below:

      Numerator
      exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
          where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period",
            end of "Measurement Period"]
          )
      )
      Show
      Thank you for your inquiry about self reports for CMS125v11 and CMS125v12, Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented. Self-reported mammography is an acceptable criterion for this measure given the mammogram is performed within the required timeframe and documented using a code from the "Mammography value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018). Having a result from the mammogram is not a requirement to meeting numerator compliance, as expressed in the logic below: Numerator exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram     where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period",       end of "Measurement Period"]     ) )
    • CMS0125v12
    • CMS0125v11

      Previously in CMS 125v10, the Guidance stated that patients can self report their mammograms. There is nothing mentioned about this in v11 or v12, but it also does not say this is NOT allowed. Is self reporting still acceptable criteria for this measure? If so, is the clinician required to have the reported result on file if they document the self reported mammogram? 

      Thanks. 

            edave Mathematica EC eCQM Team
            Smayhall Susan Mayhall
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