[CQM-6667] Draft eCQM Logic and Implementation Guidance Created: 12/27/23  Updated: 01/24/24  Resolved: 01/24/24

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: Other Priority: Moderate
Reporter: Mathematica EC eCQM Team (Inactive) Assignee: Mathematica EC eCQM Team (Inactive)
Resolution: Resolved Votes: 0
Labels: CRP

Attachments: Microsoft Word DRAFT-eCQM-Logic-and-Guidance-v8.docx    
2025 Performance Period EC eCQMs:
Not measure related
Last Commented Date:

 Description   

eCQM Issue Tracker

The electronic clinical quality measure (eCQM) Issue Tracker provides a public place for the eCQM community to submit questions and provide feedback related to eCQM specifications.

 ** 

Reminder: Do not include any Protected Health Information (PHI) in the ONC Project Tracking System.

  

Annual Update (AU) Reading and Logic Guides

 The Centers for Medicare & Medicaid Services (CMS) invites vendors and implementers to review and provide feedback on supporting resources for the upcoming electronic clinical quality measure (eCQM) annual update publication for 2025 reporting. Vendors and implementers are invited to review and comment on the DRAFT Guide for Reading eCQMs and DRAFT eCQM Logic and Implementation Guidance document.

 

The public comment period for the AU Guides will be open from 01/03 through 01/23.

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CQM-6666: Draft Guide for Reading eCQMs

CQM-6667: Draft eCQM Logic and Implementation Guidance

 

The eCQM Logic and Implementation Guidance includes details to assist implementers for the eCQMs, including defining how specific logic and data elements should be conceptualized and addressed during eCQM implementation. It also provides information to interested parties on how to use ONC Project Tracking (Jira), the CMS and ONC feedback system, to provide feedback, track issues, and ask questions about measure intent, specifications, certification, standards, and issues uncovered during implementation associated with the eCQMs.

 

The Guide for Reading eCQMs is designed to help providers, quality analysts, implementers, and Health Information Technology vendors understand eCQMs and eCQM-related documents. The guide provides background on an eCQM package, the building blocks of an eCQM, and an overview of understanding the human-readable format of the eCQM.

 

For more information on how to use the ONC Project Tracking System, visit the Learning Resources page.

 Comments   
Comment by Mathematica EC eCQM Team (Inactive) [ 01/24/24 ]

The comment period is now closed. Thank you for your comments on the Draft eCQM Logic and Implementation Guidance! We are reviewing your feedback and will follow up, as needed.

Comment by kim crady [ 01/05/24 ]

Hello JIRA,

eCQM 6667

  • No mention of hospital systems transferring within their health system. They might share same CCN, therefore should be addressed.  This is especially true for free-standing ED’s and the outpatient STEMI measure.
  • This is a logic guide for all except the hybrid measures? You refer back to eCQI Resource Center.
  • On 4.5 section- there needs to be expanded discussion and additions to the value sets to include ICD 10 codes where relevant medications or medication classes are appropriate.

Example: CMS996 v4

 ICD10  Z79.01 Long term (current) use of anticoagulants.

At the start of ED encounter:

  • Bleeding or bleeding diathesis (excluding menses)
  • Known malignant intracranial neoplasm (primary or metastatic)
  • Known structural cerebral vascular lesion (e.g., AVM)
  • Advanced dementia
  • Pregnancy
  • Active oral anticoagulant therapy{}

RX Norms only are captured if administered, ordered, continued, prescribed, etc. RXNORM relationships would not apply in certain situations.

 

Example: Outpatient STEMI measure

ICD10   Z92.82 Status post administration of TPA in a different facility within the last 24 hours prior to admission to current facility.

We would not repeat TPA at the receiving facility. (same CCN- or different CCN)

 

Just a quick look at these- Thanks for giving the opportunity to help created more user-friendly guides.

Thanks,

Kim

 

Comment by Aleksandr Kladnitsky [ 01/04/24 ]

It would be great if the guide discusses how clinics with multiple specialties should decide on which provider types to include in which eCQMs. Currently, many eCQMs include E&M codes that are used by multiple specialties. Differences between organizations can thus be a result of which providers the organization decides to include in the eCQM. Specifically, some organizations may include primary care and behavioral health in the diabetes eCQM CMS122 while others would only include primary care in the diabetes CMS 122 eCQM.

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