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  1. eCQM Issue Tracker
  2. CQM-6714

eCQM clarifications

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      Thank you for your inquiry about CMS165v12, Controlling High Blood Pressure (2024 performance period).
      Per the measure specification, the measurement period is defined as "January 1, 20XX through December 31, 20XX" of the performance year, i.e., January 1, 2024 through December 31, 2024. In general, the phrase "by the end of the measurement period" is defined as an event that must occur anytime on or before December 31st of the measurement period. It is correct that determining the acceptability, reliability and validity of the device used is left to the discretion of the clinician.

      Thank you for your inquiry regarding CMS2v13, Preventative Care and Screening: Screening for Depression and Follow-Up Plan.
      a) Qualifying codes associated with identifying a history of bipolar disorder can be found in the Value Set "Bipolar Disorder" (2.16.840.1.113883.3.67.1.101.1.128). The value set can be found on The National Library of Medicine's Value Set Authority Center (VSAC), https://vsac.nlm.nih.gov/. The VSAC provides downloadable access to all official versions of value set content contained in the eCQM specifications. The value sets are lists of unique coded identifiers with names (called descriptors) for groupings of clinical and administrative concepts selected from standard vocabularies.

      b) You are correct. The measure does not dictate which tool must be used by clinicians when screening for depression. Also, the measure does not assess the quality of returned follow-up notes from referrals ordered. CMS2v13 assesses whether or not a qualifying follow-up intervention was documented based on the results of the depression screen performed using an age-appropriate standardized tool. Please see the criteria for qualifying follow-up interventions below. In the scenario you provided, documenting the order for referral for the positive depression screen meets the measure's intent.
      Follow Up Intervention for Positive Adolescent Depression Screening
      ["Medication, Order": "Adolescent Depression Medications"]
        union ["Intervention, Order": "Referral for Adolescent Depression"]
        union ["Intervention, Performed": "Follow Up for Adolescent Depression"]
       
      Follow Up Intervention for Positive Adult Depression Screening
      ["Medication, Order": "Adult Depression Medications"]
        union ["Intervention, Order": "Referral for Adult Depression"]
        union ["Intervention, Performed": "Follow Up for Adult Depression"]

      Thank you for your inquiry for the denominator exclusion in CMS122v12, Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)(2024 performance period).
      In order to meet this exclusion criteria, a patient must have an indication of frailty in addition to meeting the advanced illness criteria. It is the combination of age, frailty, and advanced illness that qualifies a patient for the exclusion. Appropriate indications of frailty mentioned below may count towards the denominator exclusion criteria when performed within the required timeframe and documented via QDM datatypes and codes below. For additional guidance on reading eCQMs, you may refer to the following resource available on the eCQI Resource Center: https://ecqi.healthit.gov/sites/default/files/Guide-for-Reading-eCQMs-v9.pdf.


      - "Device, Order" using a code from "Frailty Device" value set (2.16.840.1.113883.3.464.1003.118.12.1300)
      - "Assessment, Performed" using direct reference code "Medical equipment used" LOINC Code (98181-1) and a result documented using the "Frailty Device" value set (2.16.840.1.113883.3.464.1003.118.12.1300)
      - "Diagnosis" using a code from "Frailty Diagnosis" value set (2.16.840.1.113883.3.464.1003.113.12.1074)
      - "Encounter, Performed" using a code from "Frailty Encounter" value set (2.16.840.1.113883.3.464.1003.101.12.1088)
      - "Symptom" using a code from "Frailty Symptom" value set (2.16.840.1.113883.3.464.1003.113.12.1075)
      Hello and thank you for your inquiry on Promoting Interoperability. Unfortunately, this ticket is out of scope for the eCQM Issue Tracker. Your question has been redirected to the QualityNet Service Desk, and the following ticket has been opened for you:
      CS2137607.
      You will be contacted by their team and assigned a customer service representative who will work to resolve your inquiry. Please let us know if you have any additional questions about eCQM logic or specifications


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      Thank you for your inquiry about CMS165v12, Controlling High Blood Pressure (2024 performance period). Per the measure specification, the measurement period is defined as "January 1, 20XX through December 31, 20XX" of the performance year, i.e., January 1, 2024 through December 31, 2024. In general, the phrase "by the end of the measurement period" is defined as an event that must occur anytime on or before December 31st of the measurement period. It is correct that determining the acceptability, reliability and validity of the device used is left to the discretion of the clinician. Thank you for your inquiry regarding CMS2v13, Preventative Care and Screening: Screening for Depression and Follow-Up Plan. a) Qualifying codes associated with identifying a history of bipolar disorder can be found in the Value Set "Bipolar Disorder" (2.16.840.1.113883.3.67.1.101.1.128). The value set can be found on The National Library of Medicine's Value Set Authority Center (VSAC), https://vsac.nlm.nih.gov/ . The VSAC provides downloadable access to all official versions of value set content contained in the eCQM specifications. The value sets are lists of unique coded identifiers with names (called descriptors) for groupings of clinical and administrative concepts selected from standard vocabularies. b) You are correct. The measure does not dictate which tool must be used by clinicians when screening for depression. Also, the measure does not assess the quality of returned follow-up notes from referrals ordered. CMS2v13 assesses whether or not a qualifying follow-up intervention was documented based on the results of the depression screen performed using an age-appropriate standardized tool. Please see the criteria for qualifying follow-up interventions below. In the scenario you provided, documenting the order for referral for the positive depression screen meets the measure's intent. Follow Up Intervention for Positive Adolescent Depression Screening ["Medication, Order": "Adolescent Depression Medications"]   union ["Intervention, Order": "Referral for Adolescent Depression"]   union ["Intervention, Performed": "Follow Up for Adolescent Depression"]   Follow Up Intervention for Positive Adult Depression Screening ["Medication, Order": "Adult Depression Medications"]   union ["Intervention, Order": "Referral for Adult Depression"]   union ["Intervention, Performed": "Follow Up for Adult Depression"] Thank you for your inquiry for the denominator exclusion in CMS122v12, Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)(2024 performance period). In order to meet this exclusion criteria, a patient must have an indication of frailty in addition to meeting the advanced illness criteria. It is the combination of age, frailty, and advanced illness that qualifies a patient for the exclusion. Appropriate indications of frailty mentioned below may count towards the denominator exclusion criteria when performed within the required timeframe and documented via QDM datatypes and codes below. For additional guidance on reading eCQMs, you may refer to the following resource available on the eCQI Resource Center: https://ecqi.healthit.gov/sites/default/files/Guide-for-Reading-eCQMs-v9.pdf . - "Device, Order" using a code from "Frailty Device" value set (2.16.840.1.113883.3.464.1003.118.12.1300) - "Assessment, Performed" using direct reference code "Medical equipment used" LOINC Code (98181-1) and a result documented using the "Frailty Device" value set (2.16.840.1.113883.3.464.1003.118.12.1300) - "Diagnosis" using a code from "Frailty Diagnosis" value set (2.16.840.1.113883.3.464.1003.113.12.1074) - "Encounter, Performed" using a code from "Frailty Encounter" value set (2.16.840.1.113883.3.464.1003.101.12.1088) - "Symptom" using a code from "Frailty Symptom" value set (2.16.840.1.113883.3.464.1003.113.12.1075) Hello and thank you for your inquiry on Promoting Interoperability. Unfortunately, this ticket is out of scope for the eCQM Issue Tracker. Your question has been redirected to the QualityNet Service Desk, and the following ticket has been opened for you: CS2137607. You will be contacted by their team and assigned a customer service representative who will work to resolve your inquiry. Please let us know if you have any additional questions about eCQM logic or specifications
    • Not measure related
    • Not measure related
    • Not measure related
    • Not measure related
    • CMS0002v13, CMS0165v12
    • Not measure related
    • Not measure related
    • Not measure related
    • Not measure related

      Hello, our ACO, participating at the individual, Group, APM Entity (All Models/Programs) level, is currently reviewing the MSSP patient roster and working with the participating organizations under our ACO to further understand the details of each eCQM and admin claims measures.

       

      Can we get clarification on the following:

      1. CMS165v12 Controlling High Blood Pressure: 
        a) How does the ACO calculate the exact date of the "measurement period"?
        b) Within denominator exclusions, how long in calendar or business days is "by the end of the measurement period"?
        c) How should a clinician define "an automated blood pressure monitor"? In the measure description, " It is the clinician's responsibility and discretion to confirm the automated blood pressure monitor or device used to obtain the blood pressure is considered acceptable and reliable and whether the blood pressure reading is considered accurate before documenting it in the patient's medical record." Does this mean it's based on the clinician's personal judgement?
      2. CMS2v13 Preventive Care and Screening: Screening for Depression and Follow-Up Plan:
        a) For "Patients who have ever been diagnosed with bipolar disorder at any time prior to the qualifying encounter", is there a specific code that is associated with the specified bipolar disorder, or is this a general documentation within the EHR?
        b) For the numerator "Patients screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter", I want to confirm the tool mentioned is at the provider's discretion, and if a patient sees a referral for the follow up, the follow up behavioral health evaluation will need to mention the documented tool? For example, if primary care provider A uses the PHQ-2, patient fails, takes PHQ-9, the referred follow up will need to mention the PHQ-9 in their documentation? I ask because not all referral services are comprehensive when sending back their follow up notes, so I want to make sure our communication for documentation is very clear.
      3. CMS122v12 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%):
        a) For denominator exclusion "Exclude patients 66 and older by the end of the measurement period with an indication of frailty for any part of the measurement period...", does "indication of frailty" require a specific evaluation tool/score/code or will this vary by how the provider documents for their patients?
      4. The last topic I want to confirm is Promoting Interoperability is not required of our MSSP data submission to CMS, correct? I am under the impression that this is solely specific to MIPS. Thanks! 

       

            edave Mathematica EC eCQM Team
            wzkessler Wendy Kessler
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