Use of EHR Billing Data for Identifying Eligible Patients in eCQM Reporting (MSSP ACO)

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • 6156422036
    • ACO Health Solutions
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      Thank you for inquiring about eCQM data source requirements. CMS is not prescriptive about the source documentation for the data elements required for the measure, provided it aligns with the measure's intent and is structured. The referenced eCQMs include the following elements in the denominator outside of patient characteristic requirements for age and/or sex:
      • CMS2—qualifying encounter
      • CMS122—diabetes diagnosis, and qualifying encounter
      • CMS165—hypertension diagnosis, and qualifying encounter
      • CMS125—qualifying encounter
      The Quality Data Model (available here: https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf) specifically notes the following: "The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR.” (p. 28) "Encounters can be billable events, but are not limited to billable interactions.” (p. 32)
       
      You should work with your providers to ensure the proposed EHR-derived billing data is most accurate for their documentation practices.
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      Thank you for inquiring about eCQM data source requirements. CMS is not prescriptive about the source documentation for the data elements required for the measure, provided it aligns with the measure's intent and is structured. The referenced eCQMs include the following elements in the denominator outside of patient characteristic requirements for age and/or sex: • CMS2—qualifying encounter • CMS122—diabetes diagnosis, and qualifying encounter • CMS165—hypertension diagnosis, and qualifying encounter • CMS125—qualifying encounter The Quality Data Model (available here: https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf) specifically notes the following: "The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR.” (p. 28) "Encounters can be billable events, but are not limited to billable interactions.” (p. 32)   You should work with your providers to ensure the proposed EHR-derived billing data is most accurate for their documentation practices.
    • CMS0002v14
    • Got this note from QPP: We no longer handle any questions about the ECQM Measure specifications. These have to be answered by ONC JIRA. This question relates to identifying all eligible patients for an MSSP ACO.

      We are preparing for eCQM reporting (CMS122, CMS165, CMS2, CMS125) and have a question about data sources for determining the eligible patient population (denominator) for electronic Clinical Quality Measures (eCQMs).
      Specifically: Is it permissible to use billing data extracted from our certified EHR systems (e.g., procedure codes, diagnosis codes, or encounter data from billing records) as a supplemental source to help identify eligible patients for inclusion in the eCQM denominator?
      We understand that the core clinical elements for numerator criteria must come from structured EHR clinical data to meet eCQM specifications and CEHRT requirements. However, we are seeking clarification on whether EHR-derived billing data can be used supplementally during our internal aggregation process to assist in identifying the full all-payer eligible population (e.g., for qualifying encounters or diagnoses).
      Any guidance, references to relevant CMS documentation, or confirmation would be greatly appreciated, as this impacts our data aggregation strategy for achieving required data completeness thresholds.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            David A. Martin
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              Created:
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