[CQM-7019] CMS153v12 appears to be missing LOINC Code 36903-3 Created: 06/05/24  Updated: 06/21/24  Resolved: 06/21/24

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

Type: EC eCQMs - Eligible Clinicians Priority: Moderate
Reporter: Sarah Dobler (Inactive) Assignee: Mathematica EC eCQM Team (Inactive)
Resolution: Answered Votes: 0
Labels: None

Attachments: Microsoft Word CMS153v11- 2.16.840.1.113883.3.464.1003.110.12.1052.xlsx     Microsoft Word CMS153v12 - 2.16.840.1.113883.3.464.1003.110.12.1052.xlsx    
Contact Name: Sarah Dobler
Contact Email: sarah.dobler@nyuhs.org
Contact Phone: 607-762-2101
Institution/Name: United Health Services Hospitals
Solution: Thank you for your inquiry for CMS153v12 Chlamydia Screening in Women. Codes that indicate a "presence" mean that the test is for the "presence" of something, and the results can be "detected" or "not detected. Therefore, it is not accurate to state that patients will only be included in the numerator if they have positive findings.

Value sets and codes for 2024 eCQM reporting once finalized cannot be amended. Clinically equivalent services may be mapped to the codes used in a measure's value sets to satisfy a value set requirement. For example, LOINC code 36903-3 which is defined as "Chlamydia trachomatis and Neisseria gonorrhoeae DNA [Identifier] in Specimen by NAA with probe detection" could be mapped to another code in the "Chlamydia Screening" (2.16.840.1.113883.3.464.1003.110.12.1052) value set. You can reference the applicable codes containing these value sets on the Value Set Authority Center (VSAC) at https://vsac.nlm.nih.gov/. Once in VSAC, click on the “Search Value Sets” tab and enter the value set ID to review codes included in the respective value set. We are unable to provide specific guidance related to the mapping of codes. We recommend you consult with your EHR vendor and clinical partners. If mapping is conducted, you should maintain documentation in case of a CMS audit.
Solution Posted On:
2024 Performance Period EC eCQMs:
CMS0153v12
2023 Performance Period EC eCQMs:
CMS0153v11
Impact: None of our patients with adequate screenings are being counted in the numerator. Our practices are all scoring 0% for this measure in 2024.

 Description   

Upon investigating the reason for our poor performance with this measure, I found that LOINC code 36903-3 used for screening is no longer included in the 2024 Chlamydia Screening value set. Code 36903-3 indicates an identifier, while the others indicate presence. By this logic, it seems if a patient is screened they will only be counted in the numerator if there are positive findings.

 Comments   
Comment by Mathematica EC eCQM Team (Inactive) [ 06/21/24 ]

We apologize for the delay in providing a response for your question. We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your continued patience.

Comment by Mathematica EC eCQM Team (Inactive) [ 06/13/24 ]

We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience.

Comment by Mathematica EC eCQM Team (Inactive) [ 06/06/24 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

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