Thank you for your inquiry about self-reports for CMS124v13, CMS125v13 and CMS130v13 (2025 Performance Period). Please see below each measure and their requirements regarding self-reported information.
For CMS124v13, self-reported HPV test is an acceptable criterion for this measure given they are performed within the required timeframe, is documented using a code from the "HPV Test" value set (OID: 2.16.840.1.113883.3.464.1003.110.12.1059), documented in a structured field in the EHR, has a non-null result, and approved for entry by a physician for the management of care. A non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required. Please see snippet of the logic below.
HPV Test Within 5 Years for Women Age 30 and Older
["Laboratory Test, Performed": "HPV Test"] HPVTest
where AgeInYearsAt(date from Global."LatestOf"(HPVTest.relevantDatetime, HPVTest.relevantPeriod))>= 30
and Global."LatestOf" ( HPVTest.relevantDatetime, HPVTest.relevantPeriod ) during day of Interval[start of "Measurement Period" - 4 years,
end of "Measurement Period"]
and HPVTest.result is not null
For CMS130v13, self-reported screenings are an acceptable criterion for this measure. Applicable screenings to meet the numerator criteria may include fecal occult blood test, FIT-DNA test, flexible sigmoidoscopy, CT colonography, or a colonoscopy. The applicable screenings mentioned above may count towards the numerator when performed within the required timeframe and documented via QDM datatypes and codes below. A result is not required for the flexible sigmoidoscopy, colonoscopy, or CT colonography to be numerator compliance. A "non-null" result is required using the QDM attribute "result" for screening options such as FOBT and FIT-DNA laboratory tests. A non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required. The information above must be documented in a structured field in the EHR, approved for entry by the provider. Please see details below regarding documentation required of the reporting provider to meet each measure's numerator requirements.
- "Laboratory Test, Performed" using a code from "Fecal Occult Blood Test (FOBT)" value set (2.16.840.1.113883.3.464.1003.198.12.1011)"
- "Laboratory Test, Performed" using a code from "FIT DNA" value set (2.16.840.1.113883.3.464.1003.108.12.1039)
- "Procedure, Performed" using a code from "Flexible Sigmoidoscopy" value set (2.16.840.1.113883.3.464.1003.198.12.1010)
- "Diagnostic Study, Performed" using a code from "CT Colonography" value set (2.16.840.1.113883.3.464.1003.108.12.1038)
- "Procedure, Performed" using a code from "Colonoscopy" value set (2.16.840.1.113883.3.464.1003.108.12.1020)
For CMS125v13, 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.
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"])
)
If you have questions about understanding measure 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..