External data closing eCQM gaps without full documentation

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Referred to External Party for Resolution
    • Priority: Moderate
    • Component/s: None
    • None
    • Sarah Bolynn
    • 7046715548
    • CaroMont Medical Group
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      Thank you for your inquiry. Unfortunately, this is out of scope for the eCQM Issues Tracker. We have created a ticket with the CCSQ Service Center for you with the following ticket number: CS2595099

      You will be contacted by their team and assigned a customer service representative who will work to resolve your inquiry.
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      Thank you for your inquiry. Unfortunately, this is out of scope for the eCQM Issues Tracker. We have created a ticket with the CCSQ Service Center for you with the following ticket number: CS2595099 You will be contacted by their team and assigned a customer service representative who will work to resolve your inquiry.
    • CMS0125v13
    • We are seeing external mammogram dates come in through external sources in our EMR without actual mammogram reports. This is closing gaps in our eCQM reports but we cannot validate the data. If we were to get audited, how would we handle this situation?

      Our organization is on the May 2025 version of Epic, and we allow both data from external sources (such as Care Everywhere) and claims data to satisfy quality measures. We have found several instances where external sources are satisfying breast cancer screening measures (CMS125v13), but the only thing coming across is the procedure CPT code. We are not receiving any electronic documentation or radiology reports coming across and we have been unable to obtain them. If we were to get audited, how would CMS handle situations where data came across from an external source via the EHR from a healthcare system outside our ACO and satisfied a measure without full the documentation also coming over? We are reporting via eCQMs for the MSSP program via the ACO we participate in.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Sarah Bolynn
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              Created:
              Updated:
              Resolved:
              Solution Posted On: