CMS156 Conflicting guidance

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for your inquiry for CMS156v13 (2025 performance period). Patients are attributed to providers based on the qualifying visit during the measurement period, and they are assigned to numerator membership based on prescriptions ordered during the measurement period, regardless of which provider placed the orders if they are on the same EHR system. In your example, if a patient has a qualifying visit with provider B, but has at least two orders of high-risk medications from the same drug class (per numerator specifications) from any providers, e.g., provider A, that patient would still be included in the numerator for provider B.

      The logic as it currently stands does not tie prescription orders to specific providers from the qualifying denominator encounter. This means that even if provider B did not order or prescribe any high risk medications, the patient would still fall into the numerator because of the existing orders in their record. However, if a patient has a qualifying visit with provider B and two high risk medication orders from a different provider who does not share the same EHR system, the patient would not be included in the numerator, because provider B would only have access to the medication list and not the underlying orders.

      As currently designed, the measure reflects a stricter patient safety perspective in which two qualifying orders meet numerator compliance regardless of which providers placed them. The intent also supports care coordination, where a provider who identifies a contraindication is expected to alert other involved providers.
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      Thank you for your inquiry for CMS156v13 (2025 performance period). Patients are attributed to providers based on the qualifying visit during the measurement period, and they are assigned to numerator membership based on prescriptions ordered during the measurement period, regardless of which provider placed the orders if they are on the same EHR system. In your example, if a patient has a qualifying visit with provider B, but has at least two orders of high-risk medications from the same drug class (per numerator specifications) from any providers, e.g., provider A, that patient would still be included in the numerator for provider B. The logic as it currently stands does not tie prescription orders to specific providers from the qualifying denominator encounter. This means that even if provider B did not order or prescribe any high risk medications, the patient would still fall into the numerator because of the existing orders in their record. However, if a patient has a qualifying visit with provider B and two high risk medication orders from a different provider who does not share the same EHR system, the patient would not be included in the numerator, because provider B would only have access to the medication list and not the underlying orders. As currently designed, the measure reflects a stricter patient safety perspective in which two qualifying orders meet numerator compliance regardless of which providers placed them. The intent also supports care coordination, where a provider who identifies a contraindication is expected to alert other involved providers.
    • CMS0156v13
    • Depending on the response there could be very different outcomes.

      The Scenario we have is a client has a provider with a patient that has an order for a high risk medication and 1 refill. Both the original order and the refill were ordered by a different provider, but per the CQL, no provider check is being done therefore the patient is meeting the Numerator for the provider that didn't order the medication. The guidance in the spec says "The intent of the measure is to assess if the reporting provider ordered the high-risk medication(s). If the patient had a high-risk medication previously prescribed by another provider, they would not be counted towards the numerator unless the reporting provider also ordered a high-risk medication from the same drug class for them".

      According to CQM-3124, the statement in the specification guidance is correct but in CQM-5152, it states "The measure as currently designed represents a stricter patient safety standpoint where two orders for the patient meets numerator compliance regardless of providers. Any point at which a provider orders high-risk medications for a patient represents an opportunity to review the patient's medications to ensure they are not placed on high-risk medications inappropriately. The logic captures whether the same high risk medications were ordered on different days within the measurement period but is not able to attribute the orders to specific providers."

      Wanting to clarify if we should be doing the provider check or leave the provider check out and this patient would meet the Numerator?

        

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Joseph Long
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