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CMS Measure ID: CMS646v4    Performance/Reporting Period: 2024    NQF Number: Not Applicable
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

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for diagnosis of tuberculosis.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis of tuberculosis.
Exclusion Criteria: Excludes concepts that identify a diagnosis other than tuberculosis.

Constrained to codes in the Active Tuberculosis for Urology Care value set (2.16.840.1.113762.1.4.1151.56)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to identify concepts for diagnosis of bladder cancer.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis of bladder cancer.
Exclusion Criteria: Excludes concepts that identify a diagnosis for cancer elsewhere in the urinary tract other than the bladder.

Constrained to codes in the Bladder Cancer for Urology Care value set (2.16.840.1.113762.1.4.1151.45)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for a diagnosis of human immunodeficiency virus (HIV) disease.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that represent a diagnosis of HIV and acquired immunodeficiency syndrome.
Exclusion Criteria: No exclusions.

Constrained to codes in the HIV value set (2.16.840.1.113883.3.464.1003.120.12.1003)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for diagnosis of immunocompromising or immunodeficient conditions.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis for an immunocompromising or immunodeficient conditions.
Exclusion Criteria: No exclusions.

Constrained to codes in the Immunocompromised Conditions value set (2.16.840.1.113883.3.666.5.1940)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to identify concepts of mixed histology urothelial cell abnormalities.
Data Element Scope: This value set may use a model element related to Diagnosis.
Inclusion Criteria: Includes concepts that identify a diagnosis of urothelial cell abnormalities.
Exclusion Criteria: Excludes concepts that indicate a condition for other urothelial cell abnormalities in the urinary bladder.

Constrained to codes in the Mixed histology urothelial cell carcinoma for Urology Care value set (2.16.840.1.113762.1.4.1151.39)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for an outpatient visit.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for the comprehensive history, evaluation, and management of a patient presenting with minor to high severity problems.
Exclusion Criteria: No exclusions.

Constrained to codes in the Office Visit value set (2.16.840.1.113883.3.464.1003.101.12.1001)

QDM Datatype and Definition

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.6 addresses that concept using the diagnosis rank=1.

Timing:

  • The relevantPeriod addresses:
    • startTime - The time the encounter began (admission time).
    • stopTime - The time the encounter ended (discharge time).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
  • The locationPeriod is an attribute of the attribute facility location that addresses:
    • startTime - the time the patient arrived at the location. The time the encounter began (admission time).
    • stopTime - the time the patient departed from the location.
Value Set Description from VSAC
Clinical Focus: This value set contains RxNORM codes associated with chemotherapy agents commonly used to treat patients with advanced stages of cancer.
Data Element Scope: This would use the Medication QDM category.
Inclusion Criteria: Inclusion Criteria Inclusion Criteria.The following generic, prescribable chemotherapy agents are included in this value set: altretamine, arsenic trioxide, asparaginase, azacytidine, belinostat, bendamustine, bexarotene, bleomycin, busulfan, cabazitaxel, capecitabine, carboplatin, carmustine, chlorambucil, cisplatin, cladribine, clofarabine, cyclophosphamide, cytarabine, cytarabine liposome, dacarbazine, dactinomycin, daunorubicin, decitabine, docetaxel, doxorubicin, epirubicin, eribulin, estramustine, etoposide, floxuridine, fludarabine, fluorouracil, gemcitabine, hydroxyurea, idarubicin, ifosfamide, irinotecan, ixabepilone, lomustine, mechlorethamine, melphalan, mercaptopurine, methotrexate, mitomycin, mitotane, mitoxantrone, nelarabine, omacetaxine, oxaliplatin, paclitaxel, pegaspargase, pemetrexed, pentostatin, pralatrexate, procarbazine, ruxolitinib, streptozocin, temozolomide, teniposide, thioguanine, thiotepa, topotecan, trabectedin, vinblastine, vincristine.
Exclusion Criteria: Chemotherapy agents not listed above are excluded from this value set, including brand name drugs or brand name drug packs.

Constrained to codes in the Chemotherapy Agents for Advanced Cancer value set (2.16.840.1.113762.1.4.1151.60)

QDM Datatype and Definition

"Medication, Active"

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set is being taken by the patient. Keep in mind that when this datatype is used with timing relationships, the criterion is looking for a medication being taken for the time frame indicated by the timing relationships.

Timing:

  • relevant dateTime references the time the medication is active on the medication record if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for an active medication on the medication record that is given or taken over a time interval:
  • The relevantPeriod addresses:
    • startTime = when the medication is first known to be used (generally the time of entry on the medication list).
    • stopTime = when the medication is no longer active.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is represent concepts of medications for immunosuppressive drugs .
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes concepts that identify a medication for immunosuppressive drug therapy.
Exclusion Criteria: Excludes concepts that identify a medication not used for immunosuppression.

Constrained to codes in the Immunosuppressive Drugs for Urology Care value set (2.16.840.1.113762.1.4.1151.32)

QDM Datatype and Definition

"Medication, Active"

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set is being taken by the patient. Keep in mind that when this datatype is used with timing relationships, the criterion is looking for a medication being taken for the time frame indicated by the timing relationships.

Timing:

  • relevant dateTime references the time the medication is active on the medication record if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for an active medication on the medication record that is given or taken over a time interval:
  • The relevantPeriod addresses:
    • startTime = when the medication is first known to be used (generally the time of entry on the medication list).
    • stopTime = when the medication is no longer active.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of medications of Bacillus Calmette Guerin (BCG) .
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes concepts that identify a medication of Bacillus Calmette Guerin (BCG) for intravesical use.
Exclusion Criteria: No exclusions.

Constrained to codes in the BCG Bacillus Calmette Guerin for Urology Care value set (2.16.840.1.113762.1.4.1151.52)

QDM Datatype and Definition

"Medication, Administered"

Data elements that meet criteria using this datatype should document that the medication indicated by the QDM category and its corresponding value set was actually administered to the patient.

Timing:

  • relevant dateTime references the time the medication is administered if it was given or taken at a single point in time.
  • relevantPeriod references a start and stop time for medication administration if the administration event occurred over a time interval (e.g., an intravenous infusion). The relevantPeriod addresses:
    • startTime - when a single medication administration event starts (e.g., the initiation of an intravenous infusion).
    • stopTime - when a single medication administration event ends (e.g., the end time of the intravenous infusion).
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes:

  • Measure developers should address multiple administrations over a period of time using CQL logic.
  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

Refer to Special Cases in Section 5.7 for scenarios to consider in calculating cumulative medication duration.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to identify concepts for the unavailability of Bacillus Calmette Guerin (BCG).
Data Element Scope: This value set may use a model element related to Medication.
Inclusion Criteria: Includes concepts that identify a reason for the unavailability of Bacillus Calmette Guerin (BCG)
Exclusion Criteria: Excludes concepts that identify a medication of BCG administered.

Constrained to codes in the Unavailability of Bacillus Calmette Guerin for urology care value set (2.16.840.1.113762.1.4.1151.44)

QDM Attribute and Definition

negationRationale

Indicates the reason that an action was not performed. Only QDM datatypes that represent actions (e.g., performed, recommended, communication, order, dispensed) allow the negation rationale attribute. The intent is to indicate a justification that such action did not happen as expected. This attribute specifically does not address the presence or absence of information in a clinical record (e.g., documented absence of allergies versus lack of documentation about allergies). QDM assumes a world view that absence of evidence indicates information does not exist or an action did not happen. To express such lack of evidence, an eCQM author should use the CQL expression not exists with reference to the data element rather than the QDM data model. negation rationale in QDM signifies only a reason for such absence, i.e., the reason must be present to qualify for negation rationale. The syntax in the human readable HQMF is addressed in CQL examples and in the MAT User Guide. Prior versions of QDM used the syntax, Procedure, Performed not done. QDM versions starting with 5.3 use the syntax, Procedure, not Performed. Section A-5 provides examples for expressing negation rationale in CQL.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.

For updated guidance and implementer feedback regarding use of the QDM negation rationale attribute see Section 6.6.

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition

"Patient Characteristic, Ethnicity"

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using "Patient Characteristic, Ethnicity" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Categories of types of health care payer entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition

"Patient Characteristic, Payer"

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing:

The relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition

"Patient Characteristic, Race"

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using "Patient Characteristic, Race" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition

"Patient Characteristic, Sex"

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Direct Reference Code

Constrained to 'Combined radiotherapy (procedure)' SNOMEDCT code

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for procedures of cystectomy.
Data Element Scope: This value set may use a model element related to Procedure.
Inclusion Criteria: Includes concepts that identify a procedure of cystectomy.
Exclusion Criteria: Excludes concepts that identify a surgery for the bladder other than cystectomy.

Constrained to codes in the Cystectomy for Urology Care value set (2.16.840.1.113762.1.4.1151.55)

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.
Direct Reference Code

Constrained to 'Tumor staging (tumor staging)' SNOMEDCT code

QDM Datatype and Definition

"Procedure, Performed"

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the procedure is performed when the procedure occurs at a single point in time.
  • relevantPeriod references a start and stop time for a procedure that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the procedure begins.
    • stopTime - The time the procedure ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes: 

  • Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  • The incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
  • negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
  • See section 6.4 for guidance about differentiating between successful and unsuccessful procedures.