CMS50V13 Clarifying Denominator for Monthly Compliance Reporting Purposes

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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    • John Buen
    • Buenj
    • 347 931 1615
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      Thank you for inquiring about the Closing the Referral Loop: Receipt of Specialist Report eCQM. Note that this measure is patient-based and therefore reported only once per year for patients with a qualifying encounter and subsequent referral to another clinician by October 31st of the measurement period (a static denominator). Only the first referral from January 1st - October 31st is used for evaluating annual performance. EHR data reporting vendors often provide compliance reports, so you may want to consult with yours to confirm before developing additional reports. Overall, you will want to monitor at least three populations:
      o Those meeting the denominator criteria;
      o The subset of the denominator where your organization has received a consultant report back (by Dec. 31st of the measurement period) for the first referral made from January 1st - October 31st (Numerator); and
      o Those that are still outstanding are the receipt of consultant reports from the first referrals placed January 1 to October 31 (opportunities for improvement), as the measure only requires that the consultant report for the first referral is received within the measurement period.

      Example
      o Qualifying encounter with first referral to cardiology 02/10/24
      o Cardiology consult report received 06/28/24
      You would want to have some internal tracking in the dates leading up to the final receipt of the consultant report, so that you are aware that the patient was not meeting the numerator criteria (opportunity for improvement), and internal QI efforts could be employed.
      Show
      Thank you for inquiring about the Closing the Referral Loop: Receipt of Specialist Report eCQM. Note that this measure is patient-based and therefore reported only once per year for patients with a qualifying encounter and subsequent referral to another clinician by October 31st of the measurement period (a static denominator). Only the first referral from January 1st - October 31st is used for evaluating annual performance. EHR data reporting vendors often provide compliance reports, so you may want to consult with yours to confirm before developing additional reports. Overall, you will want to monitor at least three populations: o Those meeting the denominator criteria; o The subset of the denominator where your organization has received a consultant report back (by Dec. 31st of the measurement period) for the first referral made from January 1st - October 31st (Numerator); and o Those that are still outstanding are the receipt of consultant reports from the first referrals placed January 1 to October 31 (opportunities for improvement), as the measure only requires that the consultant report for the first referral is received within the measurement period. Example o Qualifying encounter with first referral to cardiology 02/10/24 o Cardiology consult report received 06/28/24 You would want to have some internal tracking in the dates leading up to the final receipt of the consultant report, so that you are aware that the patient was not meeting the numerator criteria (opportunity for improvement), and internal QI efforts could be employed.
    • CMS0050v13
    •  We are trying to make a monthly compliance report for this measure. We need clarification best way to do this.

      Could you clarify the definition of the denominator?
      That is for each month, is the denominator shifting by one month. 
      Example:

      • Baseline 2024 Report = January ‘24 to December’24 measurement period, considering only first referral from January ’24 – October ‘24
      • January 2025 Report = February ‘24 to January ‘25 measurement period, considering only first referral from February ’24 – November ‘24
      • February 2025 report = March ’24 to February ’25 measurement period, considering only first referral from March ’24 to December‘24
      • March 2025 report = April '24 to March'25 measurement period, considering only first referral from April ’24 to January ‘25

      Or, is it one denominator and each month we are looking at the new total of compliant charts
      Example:

      • Baseline 2024 = January ‘24 to December’24 measurement period, considering only first referral from January ’24 – October ‘24
      • January 2025 Report = considering only first referral from January ’24 – October ’24, measure for compliance until end of January 31st 2025
      • February 2025 Report = considering only first referral from January ’24 – October ’24, measure for compliance until end of February 28th 2025
      • March 2025 Report = considering only first referral from January ’24 – October ’24, measure for compliance until end of March 31st 2025

      Or, Should we be looking at denominator completely independent for the measurement period
      Example:

      • Baseline 2024 = January ‘24 to December’24 measurement period, considering only first referral from January ’24 – October ‘24
      • January 2025 = January '25 to December '25 measurement period, considering only first referral of January '25
      • February 2025 = January '25 to December '25 measurement period, considering only first referral January '25 to February '25
      • March 2025 =  January '25 to December '25 measurement period, considering only first referral January '25 to March '25

            Assignee:
            AIR EC eCQM Team
            Reporter:
            John-Conrad
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