Breast Cancer Screening Patient reported results

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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      Thank you for your inquiry regarding CMS125v14 (2026 Performance Period). Self-reported mammography is an acceptable criterion for this measure given they are performed within the required timeframe, documented using a code from the "Mammography" value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018), and documented in a structured field in the EHR, approved for entry by a physician for the management of care. Having a result from the mammogram is not a requirement to meeting numerator compliance, but the measure specification requires documentation as expressed in the logic below.

      If you have questions about reading the measure specification or understanding data 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. If you have questions regarding CMS quality program reporting requirements, please review the QPP website or contact the QPP Helpdesk at QPP@cms.hhs.gov.

      Numerator
      exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram
      where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", end of "Measurement Period"])
      )
      Show
      Thank you for your inquiry regarding CMS125v14 (2026 Performance Period). Self-reported mammography is an acceptable criterion for this measure given they are performed within the required timeframe, documented using a code from the "Mammography" value set (OID: 2.16.840.1.113883.3.464.1003.108.12.1018), and documented in a structured field in the EHR, approved for entry by a physician for the management of care. Having a result from the mammogram is not a requirement to meeting numerator compliance, but the measure specification requires documentation as expressed in the logic below. If you have questions about reading the measure specification or understanding data 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 . If you have questions regarding CMS quality program reporting requirements, please review the QPP website or contact the QPP Helpdesk at QPP@cms.hhs.gov . Numerator exists ( ["Diagnostic Study, Performed": "Mammography"] Mammogram where ( Global."NormalizeInterval" ( Mammogram.relevantDatetime, Mammogram.relevantPeriod ) ends during day of Interval["October 1 Two Years Prior to the Measurement Period", end of "Measurement Period"]) )
    • CMS0125v14

      Are patient-reported results acceptable to meet the numerator criteria for breast cancer screening? If so, what code should be used to meet the numerator criteria if there is no report available in the chart and would this be satisfactory in the event of an audit?

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Lauren
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              Created:
              Updated:
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