eCQM 318 "Falls: Screening for Future Fall Risk" numerator question

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Renee Freyer
    • 865-643-8206
    • Verana Health, MIPS Registry
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      Thank you for your inquiry regarding CMS139v14 (2026 Performance Period). The eCQMs are designed to use clinical data from structured fields in the EHR, as opposed to billing/claims data. This measure looks for the percentage of every patient 65 years of age and older, who had a qualifying encounter visit during the measurement period, and were screened for future fall risk at least once within the measurement period. The measure's numerator looks for documentation of an assessment via QDM datatype "Assessment, Performed" encoded with any of the following codes from the “Falls Screening” value set (2.16.840.1.113883.3.464.1003.118.12.1028) that is performed on a date/time during the measurement period. The data must be entered and documented into an EHR.

      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. For inquiries about CMS quality program reporting requirements or other quality measure collection types (e.g., MIPS CQM), please contact the QPP Helpdesk at QPP@cms.hhs.gov.
      Show
      Thank you for your inquiry regarding CMS139v14 (2026 Performance Period). The eCQMs are designed to use clinical data from structured fields in the EHR, as opposed to billing/claims data. This measure looks for the percentage of every patient 65 years of age and older, who had a qualifying encounter visit during the measurement period, and were screened for future fall risk at least once within the measurement period. The measure's numerator looks for documentation of an assessment via QDM datatype "Assessment, Performed" encoded with any of the following codes from the “Falls Screening” value set (2.16.840.1.113883.3.464.1003.118.12.1028) that is performed on a date/time during the measurement period. The data must be entered and documented into an EHR. 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 . For inquiries about CMS quality program reporting requirements or other quality measure collection types (e.g., MIPS CQM), please contact the QPP Helpdesk at QPP@cms.hhs.gov .
    • CMS0139v14

      Numerator requirement - Can a practice call Not Met numerator patients to ask falls risk related questions, requesting their answers be specific to the date in which they were denominator eligible?

      If Yes, the medical team could enter details in a non-billable encounter to satisfy numerator requirements.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Renee Freyer
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