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  1. eCQM Issue Tracker
  2. CQM-7474

Clarification on females surgically transitioned to males in female only measures.

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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    • None
    • None
    • Tracy Tipton
    • 480-861-2514
    • Banner Health
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      Thank you for your question regarding CMS124v13 (2025 Performance Period) and CMS125v13 (2025 Performance Period). As specified in the measure specifications, the Initial Population/Denominator is looking for female patients identified by the code "Female" ("AdministrativeGender Code (F)"). Any patient with administrative sex of F who does not meet exclusion criteria must be included in the measure; there are currently no exclusion for those who have undergone gender-affirming surgical procedures.

      For general questions about eCQM supplemental data element for sex, please refer to resources on the eCQI resource center such as "Guide for Reading eCQMs" (https://ecqi.healthit.gov/sites/default/files/2025-Guide-for-Reading-eCQMs.pdf#page=19) or "eCQM Logic and Implementation Guidance" (https://ecqi.healthit.gov/sites/default/files/2025-eCQM-Logic-and-Guidance.pdf#page=28).
      Show
      Thank you for your question regarding CMS124v13 (2025 Performance Period) and CMS125v13 (2025 Performance Period). As specified in the measure specifications, the Initial Population/Denominator is looking for female patients identified by the code "Female" ("AdministrativeGender Code (F)"). Any patient with administrative sex of F who does not meet exclusion criteria must be included in the measure; there are currently no exclusion for those who have undergone gender-affirming surgical procedures. For general questions about eCQM supplemental data element for sex, please refer to resources on the eCQI resource center such as "Guide for Reading eCQMs" ( https://ecqi.healthit.gov/sites/default/files/2025-Guide-for-Reading-eCQMs.pdf#page=19 ) or "eCQM Logic and Implementation Guidance" ( https://ecqi.healthit.gov/sites/default/files/2025-eCQM-Logic-and-Guidance.pdf#page=28 ).
    • CMS0125v13
    • Moderate

      With female only measures such as CMS 124 Cervical Cancer Screening or CMS125 Breast Cancer Screening, is it expected that a female who has surgically transitioned to a male should still be included in the female only measures?

            AIR EC eCQM Team AIR EC eCQM Team
            TiptonT Tracy Tipton
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