Hello and thank you for your inquiry about CMS50v14 Closing the Referral Loop: Receipt of Specialist Report. The measure is designed to capture all qualifying encounters in which a referral was ordered. 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.   The measure does not provide guidance on how to handle situations where the patient does not see the specialist, regardless of the reason. At this time the measure can only be met if a consultant report is received from the clinician to whom the patient was referred as this is the intent of the measure. This measure is not a mandatory measure for eCQM reporting; eligible clinicians can self-select from the list of voluntary eCQMs for reporting to CMS. We will investigate cases where patients do not attend referral appointments and may consider addressing this in a future update cycle.