Thank you for your inquiry about CMS125v13 (2025 Performance Period). The eCQM value set for this measure utilizes LOINC codes in alignment with the CMS Measures Management System (MMS) Blueprint. Specifically, the data criteria for 'Mammography' are categorized under the clinical concept of 'Diagnostic Study,' which per Blueprint requirements, must use the LOINC coding system. For your reference, please find the relevant Blueprint documentation linked below. Equivalent services may be mapped to the measure's value sets. If mapping is done, you should maintain documentation in case of a CMS audit. Supplemental Material to the CMS MMS Blueprint, Codes, Code Systems, and Value Sets, Appendix. QDM Categories with ONC Health Information Technology Standards Committee (HITSC) Recommended Vocabularies: https://www.cms.gov/files/document/blueprint-codes-code-systems-value-sets.pdf#page=25 CMS Measures Management System Blueprint Version 17.0: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/MMS-Blueprint

If the mammogram eCQM numerator only accepts LOINC codes but our client’s source data provides CPT and CPT II codes, the measure may undercount patients who meet numerator criteria. Without a crosswalk, valid mammogram results coded with CPT/CPT II would be excluded, potentially resulting in: Lower quality scores due to incomplete numerator data Inaccurate reporting to CMS and other regulatory bodies Misrepresentation of provider performance impacting reimbursement or compliance Why This Is Problematic eCQM logic is value-set driven, and if the value set only accepts LOINC codes, any other coding standard (e.g., CPT) is ignored unless mapped. Without an approved crosswalk, we risk discarding valid clinical data, creating reporting gaps and reducing data integrity across the measure set.