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  1. eCQM Issue Tracker
  2. CQM-6786

Deceased, Ineligible, and completed data skewing numbers.

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    • Icon: EH/CAH eCQMs EH/CAH eCQMs
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Justin K Beldo
    • 218-335-3290
    • Cass Lake IHS Critical Access Hospital
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      Thank you for your inquiry about CMS130v11: Colorectal Cancer Screening. This measure is currently not specified to capture and exclude patients who are deceased during the measurement period. This measure does capture all patients with a qualifying visit during the measurement period in the denominator.

      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. You may refer to the measure specification to further review all other requirements/data criteria, e.g., initial population, denominator, denominator exclusions, etc. 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.

      - "Laboratory Test, Performed" 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" using a code from "FIT DNA" value set (2.16.840.1.113883.3.464.1003.108.12.1039)
      - "Procedure, Performed" using a code from "Flexible Sigmoidoscopy" value set (2.16.840.1.113883.3.464.1003.198.12.1010)
      - "Diagnostic Study, Performed" using a code from "CT Colonography" value set (2.16.840.1.113883.3.464.1003.108.12.1038)
      - "Procedure, Performed" using a code from "Colonoscopy" value set (2.16.840.1.113883.3.464.1003.108.12.1020)
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      Thank you for your inquiry about CMS130v11: Colorectal Cancer Screening. This measure is currently not specified to capture and exclude patients who are deceased during the measurement period. This measure does capture all patients with a qualifying visit during the measurement period in the denominator. 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. You may refer to the measure specification to further review all other requirements/data criteria, e.g., initial population, denominator, denominator exclusions, etc. 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 . - "Laboratory Test, Performed" 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" using a code from "FIT DNA" value set (2.16.840.1.113883.3.464.1003.108.12.1039) - "Procedure, Performed" using a code from "Flexible Sigmoidoscopy" value set (2.16.840.1.113883.3.464.1003.198.12.1010) - "Diagnostic Study, Performed" using a code from "CT Colonography" value set (2.16.840.1.113883.3.464.1003.108.12.1038) - "Procedure, Performed" using a code from "Colonoscopy" value set (2.16.840.1.113883.3.464.1003.108.12.1020)
    • CMS0130v11
    • Possibly incorrectly reporting of our eCQMs.

      Upon review of our eCQM colonoscopy patient list it was discovered in the first 20 patients that one patient on the list died in April 2023 with date of death documented same month in our EHR, one patient was ineligible (non-beneficiary) for care at Cass Lake IHS Hospital, and another patient had a documented CPT code for colonoscopy done. These 3 patients were in the list as counting against us for not having the colonoscopy done. Do you have guidance on if ineligible patients and deceased patients' criteria should be included in the CMS measures? We want to ensure we our abstracted data is running accurately.

            edave Mathematica EC eCQM Team
            justin.beldo@ihs.gov Justin K Beldo
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