Metadata
Title | Intravesical Bacillus-Calmette-Guerin for Non-Muscle Invasive Bladder CancerFHIR
Version | 1.0.000
Short Name | CMS646FHIR
GUID (Version Independent) | urn:uuid:907ead5a-2f8f-468e-b774-309ea8aa6182
GUID (Version Specific) | urn:uuid:67c8554c-9288-4de2-b8dc-45ae4673e032
CMS Identifier | 646FHIR
Effective Period | 2026-01-01 through 2026-12-31
Steward (Publisher) | Oregon Urology
Developer | Oregon Urology
Description | Percentage of patients initially diagnosed with non-muscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of bladder cancer staging
Copyright | Limited proprietary coding is contained in the measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. Oregon Urology Institute (OUI) and Large Urology Group Practice Association (LUGPA) disclaim all liability for the use or accuracy of third-party codes contained in the specifications. CPT(R) contained in the Measure specifications is copyright 2004-2024. American Medical Association. LOINC(R) copyright 2004-2024 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2024 International Health Terminology Standards Development Organisation. ICD-10 copyright 2024 World Health Organization. All Rights Reserved.
Disclaimer | The performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by TM or [TM].
Rationale | Bladder cancer is ranked 10th for new cancer cases in 2020 and is the ninth leading cause of cancer death in the United States. There are 81,400 estimated new cases in 2020 and 17,980 estimated deaths in 2020. In 2016, an estimated 699,450 people were living with bladder cancer in the United States. Early detection (discovery of cancer in situ or localized to the primary site) is found in 85% of the patients, and with these there is a five-year survival rate of 95.8% for In Situ and 69.2% for Localized. Bladder cancer is rarely found in patients under age 20, with the median age of diagnosis being 73 (NIH, 2020). National Comprehensive Cancer Network (NCCN) Guidelines for Bladder Cancer (version 6.2021) defines intravesical BCG as Category 1 Treatment for T1, Tis and Ta - high grade, non-muscle invasive bladder cancer. Most public data reflects prophylactic or adjuvant use of intravesical therapy to prevent recurrence or delay progression to a higher grade or stage. BCG has been shown to be effective as prophylaxis to prevent bladder cancer recurrences following TURBT. The NCCN Bladder Cancer Panel Members recommend BCG as the preferred option over Mitomycin C for adjuvant treatment of high-grade lesions (Ta). BCG is also standard therapy for Primary Tis. Most T1 lesions are high-risk and are similarly treated with adjuvant intravesical therapy, with BCG being a Category 1 recommendation (NCCN, 2021).
Clinical Recommendation Statement | Intravesical BCG should be administered within 6 months of the initial diagnosis of non-muscle invasive bladder cancer. It may be administered 3-4 weeks after resection, but there needs to be pathological tumor confirmation and must be withheld if there is traumatic catheterization, bacteriuria, persistent gross hematuria, persistent severe local symptoms or systemic symptoms. The normal induction course is 6 weekly instillations of intravesical BCG (AUA Non-Muscle Invasive Bladder Cancer and American Urological Association (AUA) Guideline for the Management of Non-muscle Invasive Bladder Cancer: Stages T1, TIS, and Ta High Risk).
Citation | Chamie, K., Saigal, C.S., Lai, J., Hanley, J.M., Setodji, C.M., Konety, B.R., ... Urologic Diseases in America Project (2011). Compliance with Guidelines for Patients with Bladder Cancer: Variation in the Delivery of Care. Cancer.2011 Dec 1: 117(23): 5392-5401. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3206145/
Citation | Chang, S.S., Boorjian, S.A., Chou, R., Clark, P.E., Daneshmand, S., Konety, B.R., ... Mckiernan, J. M., (2016) American Urological Association. Non-Muscle Invasive Bladder Cancer. https://www.auanet.org/guidelines-and-quality/guidelines/bladder-cancer-non-muscle-invasive-guideline
Citation | Hall, M.C., Chang, S.S., Dalbagni, G., Pruthi, R.S., Schellhammer, P.F., Seigne, J.D., ... Wolf, S., (2016). American Urological Association. Guideline for the Management of Non-muscle Invasive Bladder Cancer (Stages Ta, T1, and Tis): Update 2016. https://www.auajournals.org/doi/10.1016/j.juro.2007.09.003
Citation | Kassouf, W., Black, P., (2016) Treatment of primary non-muscle invasive urothelial bladder cancer. Literature review current through Dec. 2016. https://www.uptodate.com/contents/treatment-of-primary-non-muscle-invasive-urothelial-bladder-cancer?source=search_result&search=Treatment%20of%20primary%20non-muscle%20invasive%20urothelial%20bladder%20cancer&selectedTitle=1~150 T of primary
Citation | National Cancer Institute. (2020). SEER Cancer Stat Facts: Bladder Cancer. Surveillance, Epidemiology, and End Results Program. U.S. Department of Health and Human Services, National Institutes of Health. https://seer.cancer.gov/statfacts/html/urinb.html
Citation | NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). (2021). Bladder Cancer. Version 6.2021. https://www.nccn.org/professionals/physician_gls/pdf/bladder.pdf
Citation | Pacific Northwest Evidence-based Practice Center, Oregon Health & Science University. (2016). PCORI Topic Brief. Comparative Effectiveness of Treatments for Non-Muscle-Invasive Bladder Cancer http://www.pcori.org/sites/default/files/PCORI-Assessment-Options-Advisory-Panel-Fall-2016-Topic-Brief-Non-Muscle-Invasive-Bladder-Cancer.pdf
Definition | Bacillus Calmette-Guerin (BCG) : A live attenuated strain of Mycobacterium bovis, first indicated as a tuberculosis vaccine, has had widespread use in intravesical immunotherapy since the 1970s
Definition | Histology: Urothelial carcinoma
Definition | Intravesical: Within the urinary bladder
Definition | Primary Tumor (T) Stage - T1: The tumor invades subepithelial connective tissue (high grade or low grade)
Definition | Primary Tumor (T) Stage - Ta: Noninvasive and high grade
Definition | Primary Tumor (T) Stage - Tis: Carcinoma in situ: "flat tumor"
Definition | Tumor Location: Urinary bladder
Guidance (Usage) | Ta bladder cancer must be high grade Ta only and is supported by the 2016 AUA guidelines and 2018 NCCN guidelines. The BCG dose can be full or partial and can be from any lot or manufacturer. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This FHIR-based measure has been derived from the QDM-based measure CMS646v6. Please refer to the HL7 QI-Core Implementation Guide (https://hl7.org/fhir/us/qicore/STU6/) for more information on QI-Core and mapping recommendations from QDM to QI-Core STU 6 (https://hl7.org/fhir/us/qicore/STU6/qdm-to-qicore.html).
Measure Group (Rate) (ID: Group_1)
Basis | boolean
Scoring | [http://terminology.hl7.org/CodeSystem/measure-scoring#proportion: 'Proportion']
Type | [http://terminology.hl7.org/CodeSystem/measure-type#process: 'Process']
Improvement Notation | [http://terminology.hl7.org/CodeSystem/measure-improvement-notation#increase: 'Increased score indicates improvement']
Initial Population | ID: InitialPopulation_1 Description: All patients initially diagnosed with T1, Tis or high grade Ta non-muscle invasive bladder cancer with bladder cancer staging within 6 months before to 6 months after the start of the measurement period and a qualified encounter in the measurement period Logic Definition: Initial Population
Denominator | ID: Denominator_1 Description: Equals Initial Population Logic Definition: Denominator
Denominator Exclusion | ID: DenominatorExclusion_1 Description: Immunosuppressed patients, includes HIV and immunocompromised state, with a diagnosis prior to Bladder Cancer Staging. Immunosuppressive drug therapy starting on or before Bladder Cancer Staging. Active Tuberculosis diagnosis during the Bladder Cancer Staging. Mixed histology urothelial cell carcinoma including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease prior to Bladder Cancer Staging. Patients who undergo cystectomy, chemotherapy or radiation within 6 months prior to Bladder Cancer Staging. Logic Definition: Denominator Exclusion
Numerator | ID: Numerator_1 Description: Intravesical Bacillus-Calmette Guerin (BCG) instillation for initial dose or series: BCG is initiated within 6 months of the bladder cancer staging Logic Definition: Numerator
Denominator Exception | ID: DenominatorException_1 Description: Unavailability of BCG within 6 months after Bladder Cancer Staging Logic Definition: Denominator Exception
Supplemental Data Guidance | For every patient evaluated by this measure also identify payer, race, ethnicity and sex
Supplemental Data Elements
Supplemental Data Element | ID: sde-ethnicity Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Ethnicity Logic Definition: SDE Ethnicity
Supplemental Data Element | ID: sde-payer Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Payer Logic Definition: SDE Payer
Supplemental Data Element | ID: sde-race Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Race Logic Definition: SDE Race
Supplemental Data Element | ID: sde-sex Usage Code: [http://terminology.hl7.org/CodeSystem/measure-data-usage#supplemental-data] Description: SDE Sex Logic Definition: SDE Sex
Measure Logic
Primary Library | https://madie.cms.gov/Library/CMS646FHIRIntravesicalBCGTherapy
Contents | Population Criteria Logic Definitions Terminology Dependencies Data Requirements
Population Criteria
Measure Group (Rate) (ID: Group_1)
Initial Population
    define "Initial Population":
      "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
        and "Has Qualifying Encounter"
Denominator
    define "Denominator":
      "Initial Population"
Denominator Exclusion
    define "Denominator Exclusion":
      exists "Acute Tuberculosis Diagnosis"
        or exists "Immunosuppressive Drugs"
        or exists "Cystectomy Done"
        or "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging"
        or "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging"
Numerator
    define "Numerator":
      "First BCG Administered" is not null
Denominator Exception
    define "Denominator Exception":
      exists "BCG Not Available Within 6 Months After Bladder Cancer Staging"
Logic Definitions
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Sex":
      case
        when Patient.sex = '248153007' then "Male (finding)"
        when Patient.sex = '248152002' then "Female (finding)"
        else null
      end
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Payer":
      [Coverage: type in "Payer Type"] Payer
        return {
          code: Payer.type,
          period: Payer.period
        }
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Ethnicity":
      Patient.ethnicity E
        return Tuple {
          codes: { E.ombCategory } union E.detailed,
          display: E.text
        }
Logic Definition | Library Name: SupplementalDataElements
    define "SDE Race":
      Patient.race R
        return Tuple {
          codes: R.ombCategory union R.detailed,
          display: R.text
        }
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "SDE Sex":
      SDE."SDE Sex"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Bladder Cancer Diagnosis":
      ( [ConditionProblemsHealthConcerns: "Bladder Cancer for Urology Care"]
        union [ConditionEncounterDiagnosis: "Bladder Cancer for Urology Care"] ) BladderCancer
        where ( BladderCancer.prevalenceInterval ( ) starts before day of end of "Measurement Period"
            or BladderCancer.onset.toInterval ( ) before day of end of "Measurement Period"
        )
          and BladderCancer.isVerified ( )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "First Bladder Cancer Staging Procedure":
      First([Procedure: "Tumor staging (tumor staging)"] BladderCancerStaging
          with "Bladder Cancer Diagnosis" BladderCancer
            such that BladderCancerStaging.performed.toInterval() starts on or before day of start of BladderCancer.prevalenceInterval()
          where BladderCancerStaging.status = 'completed'
          sort by start of performed.toInterval()
      )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "First BCG Administered":
      First([MedicationAdministration: "Bacillus Calmette Guerin for Urology Care"] BCG
          with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
            such that BCG.effective.toInterval() starts 6 months or less after day of start of FirstBladderCancerStaging.performed.toInterval()
              and BCG.effective.toInterval() starts during day of "Measurement Period"
          where BCG.status in { 'in-progress', 'completed' }
          sort by start of effective.toInterval()
      )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Numerator":
      "First BCG Administered" is not null
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "BCG Not Available Within 6 Months After Bladder Cancer Staging":
      [MedicationAdministrationNotDone: "Bacillus Calmette Guerin for Urology Care"] BCGNotGiven
        with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
          such that BCGNotGiven.recorded 6 months or less after day of start of FirstBladderCancerStaging.performed.toInterval ( )
        where BCGNotGiven.statusReason in "Unavailability of Bacillus Calmette Guerin for Urology Care"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Denominator Exception":
      exists "BCG Not Available Within 6 Months After Bladder Cancer Staging"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "July 1 of Year Prior to the Measurement Period":
      Date((year from start of "Measurement Period" - 1), 7, 1)
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "June 30 of the Measurement Period":
      Date((year from start of "Measurement Period"), 6, 30)
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period":
      "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
        where FirstBladderCancerStaging.performed.toInterval ( ) during day of Interval["July 1 of Year Prior to the Measurement Period", "June 30 of the Measurement Period"]
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    /*Ta High Grade only to be included.  Ta low grade is to be excluded from this measure.*/

    define "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG":
      exists ( [LaboratoryResultObservation] StagingObservation
          where StagingObservation.getStagingProcedure ( ) is not null
            and ( StagingObservation.value as Concept ~ "American Joint Committee on Cancer cT1 (qualifier value)"
                or StagingObservation.value as Concept ~ "American Joint Committee on Cancer cTis (qualifier value)"
                or StagingObservation.value as Concept ~ "American Joint Committee on Cancer cTa (qualifier value)"
                or StagingObservation.value as Concept ~ "Carcinoma in situ of bladder"
            )
            and StagingObservation.status in { 'final', 'amended', 'corrected' }
      )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Has Qualifying Encounter":
      exists ( [Encounter: "Office Visit"] ValidEncounter
          where ValidEncounter.period during day of "Measurement Period"
            and ValidEncounter.class !~ "virtual"
            and ValidEncounter.status = 'finished'
      )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Initial Population":
      "Has Most Recent Bladder Cancer Tumor Staging is T1, Tis, Ta HG"
        and "Has Qualifying Encounter"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Denominator":
      "Initial Population"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "SDE Payer":
      SDE."SDE Payer"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "SDE Ethnicity":
      SDE."SDE Ethnicity"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Acute Tuberculosis Diagnosis":
      ( [ConditionProblemsHealthConcerns: "Tuberculosis for Urology Care"]
        union [ConditionEncounterDiagnosis: "Tuberculosis for Urology Care"] ) ActiveTuberculosis
        with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
          such that ( ( ActiveTuberculosis.prevalenceInterval ( ) overlaps after day of FirstBladderCancerStaging.performed.toInterval ( ) )
              or ( ActiveTuberculosis.onset.toInterval ( ) overlaps after day of FirstBladderCancerStaging.performed.toInterval ( )
                  and ( ( ActiveTuberculosis.abatement.toInterval ( ) overlaps after day of FirstBladderCancerStaging.performed.toInterval ( ) )
                      or ( ActiveTuberculosis.abatement is null )
                  )
              )
          )
        where ActiveTuberculosis.isVerified ( )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Immunosuppressive Drugs":
      [MedicationRequest: "Immunosuppressive Drugs for Urology Care"] ImmunosuppressiveDrugs
        let firstMedicationPeriod: First((collapse(ImmunosuppressiveDrugs.dosageInstruction.timing.repeat.bounds DoseTime
              return DoseTime.toInterval()
          )) DrugPeriods
            sort by start of $this
        ),
        //get the very first event

        firstMedicationEvent: First((ImmunosuppressiveDrugs.dosageInstruction.timing dosageTiming
            //return first event for the specific dosageTiming

            return First(dosageTiming.event dosageTimingEvents
                sort ascending
            )) firstEvents
            sort ascending
        ),
        medicationPeriod: Coalesce(firstMedicationEvent.toInterval(), firstMedicationPeriod)
        with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
          such that medicationPeriod starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( )
        where ImmunosuppressiveDrugs.status in { 'active', 'completed' }
          and ImmunosuppressiveDrugs.intent = 'order'
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Cystectomy Done":
      [Procedure: "Cystectomy for Urology Care"] Cystectomy
        with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
          such that Cystectomy.performed.toInterval ( ) 6 months or less before day of start of FirstBladderCancerStaging.performed.toInterval ( )
        where Cystectomy.status = 'completed'
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging":
      exists ( ( ( [ConditionProblemsHealthConcerns: "HIV"]
            union [ConditionEncounterDiagnosis: "HIV"]
        )
          union ( [ConditionProblemsHealthConcerns: "Immunocompromised Conditions"]
              union [ConditionEncounterDiagnosis: "Immunocompromised Conditions"]
          )
          union ( [ConditionProblemsHealthConcerns: "Mixed Histology Urothelial Cell Carcinoma for Urology Care"]
              union [ConditionEncounterDiagnosis: "Mixed Histology Urothelial Cell Carcinoma for Urology Care"]
          ) ) ExclusionDiagnosis
          with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
            such that ( ( ExclusionDiagnosis.prevalenceInterval ( ) starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( ) )
                or ( ExclusionDiagnosis.onset.toInterval ( ) starts on or before day of start of FirstBladderCancerStaging.performed.toInterval ( ) )
            )
          where ExclusionDiagnosis.isVerified ( )
      )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging":
      exists ( ( [MedicationRequest: "Chemotherapy Agents for Advanced Cancer"] ExclusionMed
            let firstMedicationPeriod: First((collapse(ExclusionMed.dosageInstruction.timing.repeat.bounds DoseTime
                  return DoseTime.toInterval()
              )) DrugPeriods
                sort by start of $this
            )
            with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
              such that firstMedicationPeriod starts 6 months or less before FirstBladderCancerStaging.performed.toInterval ( )
            where ExclusionMed.status in { 'active', 'completed' }
              and ExclusionMed.intent = 'order'
        )
          union ( [Procedure: "Combined radiotherapy (procedure)"] ExclusionProcedure
              with "First Bladder Cancer Staging Procedure" FirstBladderCancerStaging
                such that ExclusionProcedure.performed.toInterval ( ) starts 6 months or less before FirstBladderCancerStaging.performed.toInterval ( )
              where ExclusionProcedure.status in { 'completed', 'in-progress' }
          )
      )
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "Denominator Exclusion":
      exists "Acute Tuberculosis Diagnosis"
        or exists "Immunosuppressive Drugs"
        or exists "Cystectomy Done"
        or "Has Excluding HIV, Immunocompromised Conditions or Mixed Histology Before Staging"
        or "Has Excluding Chemotherapy or Radiotherapy Procedure Before Staging"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define "SDE Race":
      SDE."SDE Race"
Logic Definition | Library Name: CMS646FHIRIntravesicalBCGTherapy
    define fluent function getStagingProcedure(StagingObservation LaboratoryResultObservation):
      StagingObservation.partOf StagingReference
        return "First Bladder Cancer Staging Procedure during 6 Months Prior to Measurement Period through the First 6 Months of Measurement Period" FirstBladderCancerStagingMP
          where FirstBladderCancerStagingMP.id = StagingReference.reference.getId ( )
Logic Definition | Library Name: QICoreCommon
    /*
    @description: Normalizes a value that is a choice of timing-valued types to an equivalent interval
    @comment: Normalizes a choice type of DateTime, Quanitty, Interval<DateTime>, or Interval<Quantity> types
    to an equivalent interval. This selection of choice types is a superset of the majority of choice types that are used as possible
    representations for timing-valued elements in QICore, allowing this function to be used across any resource.
    The input can be provided as a DateTime, Quantity, Interval<DateTime> or Interval<Quantity>.
    The intent of this function is to provide a clear and concise mechanism to treat single
    elements that have multiple possible representations as intervals so that logic doesn't have to account
    for the variability. More complex calculations (such as medication request period or dispense period
    calculation) need specific guidance and consideration. That guidance may make use of this function, but
    the focus of this function is on single element calculations where the semantics are unambiguous.
    If the input is a DateTime, the result a DateTime Interval beginning and ending on that DateTime.
    If the input is a Quantity, the quantity is expected to be a calendar-duration interpreted as an Age,
    and the result is a DateTime Interval beginning on the Date the patient turned that age and ending immediately before one year later.
    If the input is a DateTime Interval, the result is the input.
    If the input is a Quantity Interval, the quantities are expected to be calendar-durations interpreted as an Age, and the result
    is a DateTime Interval beginning on the date the patient turned the age given as the start of the quantity interval, and ending
    immediately before one year later than the date the patient turned the age given as the end of the quantity interval.
    If the input is a Timing, an error will be thrown indicating that Timing calculations are not implemented. Any other input will reslt in a null DateTime Interval
    */
    define fluent function toInterval(choice Choice<DateTime, Quantity, Interval<DateTime>, Interval<Quantity>, Timing>):
      case
    	  when choice is DateTime then
        	Interval[choice as DateTime, choice as DateTime]
    		when choice is Interval<DateTime> then
      		choice as Interval<DateTime>
    		when choice is Quantity then
    		  Interval[Patient.birthDate + (choice as Quantity),
    			  Patient.birthDate + (choice as Quantity) + 1 year)
    		when choice is Interval<Quantity> then
    		  Interval[Patient.birthDate + (choice.low as Quantity),
    			  Patient.birthDate + (choice.high as Quantity) + 1 year)
    		when choice is Timing then
          Message(null, true, 'NOT_IMPLEMENTED', 'Error', 'Calculation of an interval from a Timing value is not supported') as Interval<DateTime>
    		else
    			null as Interval<DateTime>
    	end
Logic Definition | Library Name: QICoreCommon
    /*
    @description: Returns the tail of the given uri (i.e. everything after the last slash in the URI).
    @comment: This function can be used to determine the logical id of a given resource. It can be used in
    a single-server environment to trace references. However, this function does not attempt to resolve
    or distinguish the base of the given url, and so cannot be used safely in multi-server environments.
    */
    define fluent function getId(uri String):
      Last(Split(uri, '/'))
Logic Definition | Library Name: FHIRHelpers
    define function ToString(value uri): value.value
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given FHIR [CodeableConcept](https://hl7.org/fhir/datatypes.html#CodeableConcept) value to a CQL Concept.
    */
    define function ToConcept(concept FHIR.CodeableConcept):
        if concept is null then
            null
        else
            System.Concept {
                codes: concept.coding C return ToCode(C),
                display: concept.text.value
            }
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given FHIR [Coding](https://hl7.org/fhir/datatypes.html#Coding) value to a CQL Code.
    */
    define function ToCode(coding FHIR.Coding):
        if coding is null then
            null
        else
            System.Code {
              code: coding.code.value,
              system: coding.system.value,
              version: coding.version.value,
              display: coding.display.value
            }
Logic Definition | Library Name: FHIRHelpers
    /*
    @description: Converts the given [Period](https://hl7.org/fhir/datatypes.html#Period)
    value to a CQL DateTime Interval
    @comment: If the start value of the given period is unspecified, the starting
    boundary of the resulting interval will be open (meaning the start of the interval
    is unknown, as opposed to interpreted as the beginning of time).
    */
    define function ToInterval(period FHIR.Period):
        if period is null then
            null
        else
            if period."start" is null then
                Interval(period."start".value, period."end".value]
            else
                Interval[period."start".value, period."end".value]
Terminology
Code System | Description: Code system SNOMEDCT Resource: http://snomed.info/sct Canonical URL: `http://snomed.info/sct`
Code System | Description: Code system ICD10CM Resource: http://hl7.org/fhir/sid/icd-10-cm Canonical URL: `http://hl7.org/fhir/sid/icd-10-cm`
Code System | Description: Code system ActCode Resource: http://terminology.hl7.org/CodeSystem/v3-ActCode Canonical URL: `http://terminology.hl7.org/CodeSystem/v3-ActCode`
Value Set | Description: Value set Bacillus Calmette Guerin for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353`
Value Set | Description: Value set Bladder Cancer for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354`
Value Set | Description: Value set Unavailability of Bacillus Calmette Guerin for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.369 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.369`
Value Set | Description: Value set Office Visit Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001`
Value Set | Description: Value set Payer Type Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591`
Value Set | Description: Value set Tuberculosis for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351`
Value Set | Description: Value set Immunosuppressive Drugs for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364`
Value Set | Description: Value set Cystectomy for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358`
Value Set | Description: Value set HIV Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003`
Value Set | Description: Value set Immunocompromised Conditions Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363`
Value Set | Description: Value set Mixed Histology Urothelial Cell Carcinoma for Urology Care Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365`
Value Set | Description: Value set Chemotherapy Agents for Advanced Cancer Resource: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355 Canonical URL: `http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355`
Direct Reference Code | Display: Male (finding) Code: 248153007 System: `http://snomed.info/sct`
Direct Reference Code | Display: Female (finding) Code: 248152002 System: `http://snomed.info/sct`
Direct Reference Code | Display: Tumor staging (tumor staging) Code: 254292007 System: `http://snomed.info/sct`
Direct Reference Code | Display: American Joint Committee on Cancer cT1 (qualifier value) Code: 1228889001 System: `http://snomed.info/sct`
Direct Reference Code | Display: American Joint Committee on Cancer cTis (qualifier value) Code: 1228884006 System: `http://snomed.info/sct`
Direct Reference Code | Display: American Joint Committee on Cancer cTa (qualifier value) Code: 1228883000 System: `http://snomed.info/sct`
Direct Reference Code | Display: Carcinoma in situ of bladder Code: D09.0 System: `http://hl7.org/fhir/sid/icd-10-cm`
Direct Reference Code | Display: virtual Code: VR System: `http://terminology.hl7.org/CodeSystem/v3-ActCode`
Direct Reference Code | Display: Combined radiotherapy (procedure) Code: 169331000 System: `http://snomed.info/sct`
Dependencies
Dependency | Description: QICore model information Resource: http://hl7.org/fhir/Library/QICore-ModelInfo Canonical URL: `http://hl7.org/fhir/Library/QICore-ModelInfo`
Dependency | Description: Library SDE Resource: https://madie.cms.gov/Library/SupplementalDataElements|5.1.000 Canonical URL: `https://madie.cms.gov/Library/SupplementalDataElements|5.1.000`
Dependency | Description: Library FHIRHelpers Resource: https://madie.cms.gov/Library/FHIRHelpers|4.4.000 Canonical URL: `https://madie.cms.gov/Library/FHIRHelpers|4.4.000`
Dependency | Description: Library QICoreCommon Resource: https://madie.cms.gov/Library/QICoreCommon|4.0.000 Canonical URL: `https://madie.cms.gov/Library/QICoreCommon|4.0.000`
Data Requirements
Data Requirement | Type: Patient Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-patient Must Support Elements: extension, birthDate, birthDate.value, url
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-problems-health-concerns Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.354
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.351
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.120.12.1003
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.363
Data Requirement | Type: Condition Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-condition-encounter-diagnosis Must Support Elements: code Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.365
Data Requirement | Type: Procedure Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure Must Support Elements: code, performed, status, status.value, id, id.value Code Filter(s): Path: code Code(s): http://snomed.info/sct#254292007: 'Tumor staging (tumor staging)'
Data Requirement | Type: Procedure Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure Must Support Elements: code, performed, status, status.value, id, id.value Code Filter(s): Path: code ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.358
Data Requirement | Type: Procedure Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-procedure Must Support Elements: code, performed, status, status.value, id, id.value Code Filter(s): Path: code Code(s): http://snomed.info/sct#169331000: 'Combined radiotherapy (procedure)'
Data Requirement | Type: MedicationAdministration Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationadministration Must Support Elements: medication, effective, status, status.value Code Filter(s): Path: medication ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353
Data Requirement | Type: MedicationAdministration Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationadministration Must Support Elements: medication.reference.value, effective, status, status.value
Data Requirement | Type: Medication Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medication Must Support Elements: id.value, code
Data Requirement | Type: MedicationAdministration Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationadministrationnotdone Must Support Elements: medication, extension, statusReason Code Filter(s): Path: medication ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.353
Data Requirement | Type: Observation Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-observation-lab Must Support Elements: value, status, status.value, reference, reference.value
Data Requirement | Type: Encounter Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-encounter Must Support Elements: type, period, class, status, status.value Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001
Data Requirement | Type: Coverage Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-coverage Must Support Elements: type, period Code Filter(s): Path: type ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591
Data Requirement | Type: MedicationRequest Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest Must Support Elements: medication, dosageInstruction, status, status.value, intent, intent.value Code Filter(s): Path: medication ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.364
Data Requirement | Type: MedicationRequest Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest Must Support Elements: medication, dosageInstruction, status, status.value, intent, intent.value Code Filter(s): Path: medication ValueSet: http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1248.355
Data Requirement | Type: MedicationRequest Profile(s): http://hl7.org/fhir/us/qicore/StructureDefinition/qicore-medicationrequest Must Support Elements: medication.reference.value, dosageInstruction, status, status.value, intent, intent.value
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