Screening Measures - backup documentation - CMS 125

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Jeanne Kessler
    • 5047230765
    • Azara Healthcare
    • Hide
      NCQA’s response:
      Thank you for your inquiry. This answer is provided specifically for CMS125v13 (2025 Performance Period); if you have questions regarding other screening measures, please submit new tickets and specify accordingly. 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, but the measure specification requires documentation as expressed in the logic below.

      If you have questions about reading the measure specification or understanding data 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. If you have questions regarding CMS quality program reporting requirements, please review the QPP website or contact the QPP Helpdesk at QPP@cms.hhs.gov.

      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
      NCQA’s response: Thank you for your inquiry. This answer is provided specifically for CMS125v13 (2025 Performance Period); if you have questions regarding other screening measures, please submit new tickets and specify accordingly. 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, but the measure specification requires documentation as expressed in the logic below. If you have questions about reading the measure specification or understanding data 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 . If you have questions regarding CMS quality program reporting requirements, please review the QPP website or contact the QPP Helpdesk at QPP@cms.hhs.gov . 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
    • Need to understand if backup documentation is needed for certain measures, both for reporting and auditing purposes. If so, our coding might need to be modified.

      Hi –

      We would like clarification on screening-related measures, including the Breast Cancer Screening measure (CMS125.)

      Can you let us know if it is acceptable to use patient-reported information alone as evidence that a screening occurred, or if additional information is needed.

      For example, if a patient reports to a provider that they have had a mammogram on a certain date, but there is no backup information provided, such as mammography report or image, and the provider enters this information into the EMR, can that information be used for measure CMS125?

      Thank you.

       

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Jeanne Kessler
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              Created:
              Updated:
              Resolved:
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