[CQM-7907] CMS 130- Cologuard Sample Not Process- Not Null Created: 05/21/25  Updated: 05/29/25  Resolved: 05/29/25

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

Type: EC eCQMs - Eligible Clinicians Priority: Moderate
Reporter: Amanda Fredricksen Assignee: AIR EC eCQM Team
Resolution: Answered Votes: 0
Labels: None

Attachments: PNG File Snap10.png    
Institution/Name: Mayo Clinic
Solution: Thank you for your inquiry about CMS130v13 (2025 performance period). Applicable screenings that meet the numerator criteria may include the following: Fecal Occult Blood Test (FOBT), Stool DNA with Fecal Immunochemical Test (FIT), Flexible Sigmoidoscopy, CT Colonography, or Colonoscopy. These screenings may count toward the numerator when performed within the measurement period and/or within the specified timeframe.

A result is not required for the flexible sigmoidoscopy, colonoscopy, or CT colonography. A "non-null" result is required for screening options such as FOBT and Stool DNA with FIT laboratory tests. An insufficient sample may count towards numerator since a non-null result can be interpreted as a result that is present in the electronic record in which any entry is acceptable; no specific value or code is required. Equivalent services can be mapped to the measure's value sets. If mapping is done, you should maintain documentation in case of a CMS audit.
Solution Posted On:
2025 Performance Period EC eCQMs:
CMS0130v13
Impact: CMS 130 colorectal samples not processed but showing as met as result is not null

 Description   

When looking at CMS 130 Colorectal Cancer Screening, we are finding several patients are showing as Met with only having a result as shown below and in screenshot (no colorectal screening actually completed):

  • Sample Could Not be Processed 9

From Epic’s perspective , they’re looking for a result that is “Not Null”, which appears to be the case in the examples provided. Submitting a JIRA ticket requesting an update to eCQM in order to make it more appropriate in the sense that it excludes results like “Sample Could Not Be Processed 9” and those listed below.

  • Sample Could Not be Processed 
  • Sample Could Not be Processed 1 
  • Sample Could Not be Processed 2
  • Sample Could Not be Processed 3
     * Sample Could Not be Processed 4
  • Sample Could Not be Processed 5 
  • Sample Could Not be Processed 6
  • Sample Could Not be Processed 7 
     * Sample Could Not be Processed 8
     * Sample Could Not be Processed 9
     * Sample Could Not be Processed 10
  • No Result Obtained
  • No Result Obtained 1
  • No Result Obtained 2
  • No Result Obtained 3
  • No Result Obtained 4
  • No Result Obtained 5

 Comments   
Comment by AIR EC eCQM Team [ 05/21/25 ]

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

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