CMS125: Breast Cancer Screening & Patient Report Results

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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      Thank you for your inquiry regarding CMS125v13 (2025 Performance Period). Self-reported mammography is an acceptable criterion for this measure given they are performed within the required timeframe, documented using a code from the "Mammography" value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018), and documented in a structured field in the EHR, approved for entry by a physician for the management of care. Having a result from the mammogram is not a requirement to meeting numerator compliance, as expressed in the logic below. For additional guidance on reading/reporting eCQM specifications, please refer to the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=0.

      Numerator
      exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
      where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", end of "Measurement Period"])
      Show
      Thank you for your inquiry regarding CMS125v13 (2025 Performance Period). Self-reported mammography is an acceptable criterion for this measure given they are performed within the required timeframe, documented using a code from the "Mammography" value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018), and documented in a structured field in the EHR, approved for entry by a physician for the management of care. Having a result from the mammogram is not a requirement to meeting numerator compliance, as expressed in the logic below. For additional guidance on reading/reporting eCQM specifications, please refer to the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=0 . Numerator exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", end of "Measurement Period"])
    • CMS0125v13

      Can patient-report mammogram results be counted in the numerator for CMS125 if no final report is documented? Clinicians are wanting to include patients who notify in the appointment that a screening was completed outside the hospital system even though there is no result report from the outside screening.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Leslie Busbee
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              Created:
              Updated:
              Resolved:
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