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  1. eCQM Issue Tracker
  2. CQM-7677

CMS125 Breast Cancer Screening

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
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      Thank you for your inquiry regarding CMS125v13 (2025 performance period). Please note that the measure logic does not require mammograms to be tied to a specific encounter. For the numerator criteria, the measure identifies at least one documented mammogram in structured EHR fields, ensuring that it was performed within the required time frame and documented via QDM datatype "Diagnostic Study, Performed" using a code from the "Mammography" value set (2.16.840.1.113883.3.464.1003.108.12.1018). The mammogram(s) can be performed any time between October 1 two years prior to the measurement period to the end of the measurement period.

      For more details on the data requirements for the numerator criteria, please refer to the measure specification: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS125v13.html. For guidance on how to read eCQM specifications, please see the following guidance on eCQI Resource Center: "https://ecqi.healthit.gov/sites/default/files/2025-Guide-for-Reading-eCQMs.pdf".
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      Thank you for your inquiry regarding CMS125v13 (2025 performance period). Please note that the measure logic does not require mammograms to be tied to a specific encounter. For the numerator criteria, the measure identifies at least one documented mammogram in structured EHR fields, ensuring that it was performed within the required time frame and documented via QDM datatype "Diagnostic Study, Performed" using a code from the "Mammography" value set (2.16.840.1.113883.3.464.1003.108.12.1018). The mammogram(s) can be performed any time between October 1 two years prior to the measurement period to the end of the measurement period. For more details on the data requirements for the numerator criteria, please refer to the measure specification: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS125v13.html . For guidance on how to read eCQM specifications, please see the following guidance on eCQI Resource Center: " https://ecqi.healthit.gov/sites/default/files/2025-Guide-for-Reading-eCQMs.pdf ".
    • CMS0125v13

      When reporting eCQM (ACO) for Breast Cancer Screening, some patients have their mammogram done at a different location other than Hattiesburg Clinic. Some of those groups will send electronically through a CCDA that the patient had the mammogram done but we do not get the report only a CPT/SNOMED/LOINC code in the background message that is sent with the CCDA (Clinical Summary). Can we count those in our eCQM if we don't have the actual report in our system?

            AIR EC eCQM Team AIR EC eCQM Team
            Noodle601 Renee Williams
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