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  2. CQM-7142

How to account for hysterectomy without official date performed or type of hysterectomy?

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • Ashwini Mathai
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      Thank you for your inquiry for CMS124v12: Cervical Cancer Screening. This measure requires a hysterectomy exclusion which excludes patients who have had a hysterectomy on or before the measurement period. Logic in this measure provides further specificity by looking at date/time and codes within the "Hysterectomy with No Residual Cervix" value set in combination to meet measure criteria. Self-reported services may be acceptable given that they are performed within the required timeframe, documented using a code from the appropriate value set: "Hysterectomy with No Residual Cervix" value set (OID: 2.16.840.1.113883.3.464.1003.198.12.1014) with the date/time and documented in a structured field in the EHR. Further explanation of this expressed in the logic below.
      Absence of Cervix
      ( ["Procedure, Performed": "Hysterectomy with No Residual Cervix"] NoCervixProcedure
      where Global."NormalizeInterval" ( NoCervixProcedure.relevantDatetime, NoCervixProcedure.relevantPeriod ) ends on or before end of "Measurement Period"
      )...
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      Thank you for your inquiry for CMS124v12: Cervical Cancer Screening. This measure requires a hysterectomy exclusion which excludes patients who have had a hysterectomy on or before the measurement period. Logic in this measure provides further specificity by looking at date/time and codes within the "Hysterectomy with No Residual Cervix" value set in combination to meet measure criteria. Self-reported services may be acceptable given that they are performed within the required timeframe, documented using a code from the appropriate value set: "Hysterectomy with No Residual Cervix" value set (OID: 2.16.840.1.113883.3.464.1003.198.12.1014) with the date/time and documented in a structured field in the EHR. Further explanation of this expressed in the logic below. Absence of Cervix ( ["Procedure, Performed": "Hysterectomy with No Residual Cervix"] NoCervixProcedure where Global."NormalizeInterval" ( NoCervixProcedure.relevantDatetime, NoCervixProcedure.relevantPeriod ) ends on or before end of "Measurement Period" )...
    • CMS0124v13
    • CMS0124v12
    • We are trying determine whether patient reported hysterectomy will suffice as an exclusion criteria - patients may not know what type of hysterectomy was performed. Does the date of the hysterectomy need to be reported- month/year?

      CMS 124v12 - We are reviewing the exclusion criteria for this measure- can it be extracted only from structured data entered in the EHR or can patient reported information " ie I had a hysterectomy in 2000" also be used? 

       

      Just to clarify because this was not clear in the response- do we need to report a Month + Date+ Year for patient reported procedures such as hysterectomy? or just year?

            AIR EC eCQM Team AIR EC eCQM Team
            Ashmath Ashwini
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