CMS ID Measure Title CMS129v1 Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low-Risk Prostate Cancer Patients CMS132v1 Cataracts: Complications within 30 Days Following Cataract Surgery Requiring Additional Surgical Procedures CMS133v1 Cataracts: 20/40 or Better Visual Acuity with 90 Days Following Cataract Surgery Measures 132 and 133 are episode based. Measure 129 is patient based. The commenter should refer to the definitions for these terms provided in the “Clinical Quality eMeasure Logic and Implementation Guidance v1.5” available at: http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2014_eCQM_LogicGuidance_June2013.pdf In order for a patient to qualify for measure inclusion, the patient must have had one of the defined procedures performed during the specified timeframe (or other requirements outlined in the eCQM specification). It is expected that the provider reporting on each of the three measures performs the quality action in the numerator. The numerator will not be evaluated unless the patient meets the denominator criteria (has a procedure performed within the given time frame). For CMS129, given that an EP cannot control another EP’s ordering of a bone scan and wouldn’t want to be penalized based on another EP’s decision, this measure allows for an exception with an example being “bone scan ordered by someone other than reporting physician”. For CMS132 and CMS133, the EP reporting on the measure could be the cataract surgeon or another eye care provider that is performing the follow up action described in the numerator. The PCPI agrees that the patient list is determined in the denominator. CMS133 specifically targets the physicians that are performing the numerator action and captures that the patient did or did not meet 20/40, regardless if they were the procedure performing physician. That said, we agree with your summarized approach, “…numerator would include patients from the denominator with 20/40 vision or better, regardless of which provider handled the follow-up appointment.” In response to the follow-up question regarding CMS 158, a provider should report if they are involved at any point during the mom’s pregnancy, prenatal care through and including the day of delivery. Of note, patients must meet the initial patient population definition to be included in this measure (i.e., age 12 and older who had a liver birth or delivery during the measurement period).