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  1. eCQM Issue Tracker
  2. CQM-7682

CMS Measures with Frailty Exclusions

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    • Icon: EC eCQMs - Eligible Clinicians EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Dalana Ostlie
    • 5093892719
    • Providence Health System
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      Thank you for your inquiry about the advanced illness and frailty exclusion criteria used in CMS122v13, CMS125v13, CMS130v13, CMS131v13 and CMS165v13 (performance period 2025). For specific details or questions regarding implementing the five measures listed above, please refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance: https://ecqi.healthit.gov/ecqm-implementation-checklist. You may find this resource on the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs. For questions about CMS quality program reporting requirements, visit the QPP website (https://qpp.cms.gov/) or contact the helpdesk at QPP@cms.hhs.gov.
      Show
      Thank you for your inquiry about the advanced illness and frailty exclusion criteria used in CMS122v13, CMS125v13, CMS130v13, CMS131v13 and CMS165v13 (performance period 2025). For specific details or questions regarding implementing the five measures listed above, please refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance: https://ecqi.healthit.gov/ecqm-implementation-checklist . You may find this resource on the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs . For questions about CMS quality program reporting requirements, visit the QPP website ( https://qpp.cms.gov/ ) or contact the helpdesk at QPP@cms.hhs.gov .
    • CMS0122v13, CMS0125v13, CMS0130v13, CMS0131v13, CMS0165v13
    • Unable to determine whether our EMR is adequately capturing all available exclusions.

      This message is regarding the 5 eCQMs within the quality payment program that has a frailty exclusion. My organization is trying to determine what the expected population of patients aged 66 and older (depending on the measure) that qualify for the exclusions might be. Is it 15%, 25%? Is there a resource or reference available that was used to create the exclusions that might give us some guidance? While this exclusion has multiple ways to capture it in documentation (symptoms, diagnosis, encounter and device) we are finding it difficult to determine if our EMR is adequately capturing all available exclusions.

            AIR EC eCQM Team AIR EC eCQM Team
            dostlie Dalana Ostlie
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