Thank you for your inquiry for CMS124v12 (2024 Performance Period) and CMS124v13 (2025 Performance Period). According to the measure steward, the National Committee for Quality Assurance (NCQA), self-reporting is acceptable given that Cervical Cytology or HPV Test reports meet the numerator requirements of the measure (are documented in the EHR, approved for entry by the provider, use codes found in the value sets "Pap Test" (OID: 2.16.840.1.113883.3.464.1003.108.12.1017) or "HPV Test" (OID: 2.16.840.1.113883.3.464.1003.110.12.1059), have a non-null result, and have a date performed within the required timeframe). Please review the measure specification logic/terminology section for detailed data requirements (see snippets below).
Cervical Cytology Within 3 Years:
["Laboratory Test, Performed": "Pap Test"] CervicalCytology where Global."LatestOf" ( CervicalCytology.relevantDatetime, CervicalCytology.relevantPeriod ) during day of Interval[start of "Measurement Period" - 2 years, end of "Measurement Period"] and CervicalCytology.result is not null
HPV Test Within 5 Years for Women Age 30 and Older:
["Laboratory Test, Performed": "HPV Test"] HPVTest where AgeInYearsAt(date from Global."LatestOf"(HPVTest.relevantDatetime, HPVTest.relevantPeriod))>= 30 and Global."LatestOf" ( HPVTest.relevantDatetime, HPVTest.relevantPeriod ) during day of Interval[start of "Measurement Period" - 4 years, end of "Measurement Period"] and HPVTest.result is not null
If you have questions about understanding measure requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center:
https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs.