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HIV Screening

Measure Information 2021 Performance Period
CMS eCQM ID CMS349v3
NQF Number Not Applicable
MIPS Quality ID 475
Description

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV

Initial Population

Patients 15 to 65 years of age at the start of the measurement period AND who had at least one outpatient visit during the measurement period

Numerator

Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday

Numerator Exclusions

Not Applicable

Denominator

Equals Initial Population

Denominator Exclusions

Patients diagnosed with HIV prior to the start of the measurement period

Denominator Exceptions

None

Steward Centers for Disease Control and Prevention (CDC)
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

Higher score indicates better quality

Guidance

This measure evaluates the proportion of patients aged 15 to 65 at the start of the measurement period who have documentation of having received an HIV test at least once on or after their 15th birthday and before their 66th birthday. In order to satisfy the measure, the reporting provider must have documentation of the administration of the laboratory test present in the patient's medical record. In cases where the HIV test was performed elsewhere, providers cannot rely on patient attestation or self-report to meet the measure requirements, as previous research has shown that patient self-report is an unreliable indicator of previous HIV testing history. Rather, providers must request documentation of those test results. If such documentation is not available, the patient should be considered still eligible for HIV screening. If such documentation is available, but cannot be provided in a standardized, structured format (such that the lab test and results can be readily incorporated as structured data within the EHR), providers should enter the information into their EHR as a laboratory test in a manner consistent with the EHR in use. If the specific Human Immunodeficiency Virus (HIV) Laboratory Test LOINC code of the test is not known, the entry should use the more generic code LOINC panel code [75622-1].

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

Telehealth Eligible Yes
Next Version
Previous Version No Version Available

Compare eCQM Versions

The Compare function compares two years of the measure specifications found in the header of the measure's HTML. It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets.

Strikethrough text highlighted in red indicates information changed from the previous version. Text highlighted in green indicates information updated in the new eCQM version.

Filter Measure By
Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period 2024 Performance Period
Title HIV Screening HIV Screening HIV Screening HIV Screening
CMS eCQM ID CMS349v3 CMS349v4 CMS349v5 CMS349v6
NQF Number Not Applicable Not Applicable Not Applicable Not Applicable
Description

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for HIV

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for Human immunodeficiency virus (HIV)

Percentage of patients aged 15-65 at the start of the measurement period who were between 15-65 years old when tested for Human immunodeficiency virus (HIV)

Initial Population

Patients 15 to 65 years of age at the start of the measurement period AND who had at least one outpatient visit during the measurement period

Patients 15 to 65 years of age at the start of the measurement period AND who had at least one outpatient visit during the measurement period

Patients 15 to 65 years of age at the start of the measurement period AND who had at least one outpatient visit during the measurement period

Patients 15 to 65 years of age at the start of the measurement period AND who had at least one outpatient visit during the measurement period

Denominator

Equals Initial Population

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions Patients diagnosed with HIV prior to the start of the measurement period Patients diagnosed with HIV prior to the start of the measurement period Patients diagnosed with HIV prior to the start of the measurement period Patients diagnosed with HIV prior to the start of the measurement period
Numerator

Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday

Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday

Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday

Patients with documentation of an HIV test performed on or after their 15th birthday and before their 66th birthday

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

None

None

None

Patients who die on or before the end of the measurement period

Measure Steward Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC)
Measure Scoring Proportion measure Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure Process measure
Improvement Notation

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Higher score indicates better quality

Guidance

This measure evaluates the proportion of patients aged 15 to 65 at the start of the measurement period who have documentation of having received an HIV test at least once on or after their 15th birthday and before their 66th birthday. In order to satisfy the measure, the reporting provider must have documentation of the administration of the laboratory test present in the patient's medical record. In cases where the HIV test was performed elsewhere, providers cannot rely on patient attestation or self-report to meet the measure requirements, as previous research has shown that patient self-report is an unreliable indicator of previous HIV testing history. Rather, providers must request documentation of those test results. If such documentation is not available, the patient should be considered still eligible for HIV screening. If such documentation is available, but cannot be provided in a standardized, structured format (such that the lab test and results can be readily incorporated as structured data within the EHR), providers should enter the information into their EHR as a laboratory test in a manner consistent with the EHR in use. If the specific Human Immunodeficiency Virus (HIV) Laboratory Test LOINC code of the test is not known, the entry should use the more generic code LOINC panel code [75622-1].

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

This measure evaluates the proportion of patients aged 15 to 65 at the start of the measurement period who have documentation of having received an HIV test at least once on or after their 15th birthday and before their 66th birthday. In order to satisfy the measure, the reporting provider must have documentation of the administration of the laboratory test present in the patient's medical record. In cases where the HIV test was performed elsewhere, providers cannot rely on patient attestation or self-report to meet the measure requirements, as previous research has shown that patient self-report is an unreliable indicator of previous HIV testing history. Rather, providers must request documentation of those test results. If such documentation is not available, the patient should be considered still eligible for HIV screening. If such documentation is available, but cannot be provided in a standardized, structured format (such that the lab test and results can be readily incorporated as structured data within the EHR), providers should enter the information into their EHR as a laboratory test in a manner consistent with the EHR in use. If the specific Human Immunodeficiency Virus (HIV) Laboratory Test LOINC code of the test is not known, the entry should use the more generic code LOINC panel code [75622-1].

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.

This measure evaluates the proportion of patients aged 15 to 65 at the start of the measurement period who have documentation of having received an HIV test at least once on or after their 15th birthday and before their 66th birthday. In order to satisfy the measure, the reporting provider must have documentation of the administration of the laboratory test present in the patient's medical record. In cases where the HIV test was performed elsewhere, providers cannot rely on patient attestation or self-report to meet the measure requirements, as previous research has shown that patient self-report is an unreliable indicator of previous HIV testing history. Rather, providers must request documentation of those test results. If such documentation is not available, the patient should be considered still eligible for HIV screening. If such documentation is available, but cannot be provided in a standardized, structured format (such that the lab test and results can be readily incorporated as structured data within the EHR), providers should enter the information into their EHR as a laboratory test in a manner consistent with the EHR in use. If the specific Human Immunodeficiency Virus (HIV) Laboratory Test LOINC code of the test is not known, the entry should use the more generic code LOINC panel code [75622-1].

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

This measure evaluates the proportion of patients aged 15 to 65 at the start of the measurement period who have documentation of having received an HIV test at least once on or after their 15th birthday and before their 66th birthday. In order to satisfy the measure, the reporting provider must have documentation of the administration of the laboratory test present in the patient's medical record. In cases where the HIV test was performed elsewhere, providers cannot rely on patient attestation or self-report to meet the measure requirements, as previous research has shown that patient self-report is an unreliable indicator of previous HIV testing history. Rather, providers must request documentation of those test results. If such documentation is not available, the patient should be considered still eligible for HIV screening. If such documentation is available, but cannot be provided in a standardized, structured format (such that the lab test and results can be readily incorporated as structured data within the EHR), providers should enter the information into their EHR as a laboratory test in a manner consistent with the EHR in use. If the specific Human Immunodeficiency Virus (HIV) Laboratory Test LOINC code of the test is not known, the entry should use the more generic code LOINC panel code [75622-1].

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

MIPS Quality ID 475 475 475 475
Telehealth Eligible Yes Yes Yes Yes
Next Version CMS349v4 CMS349v5 CMS349v6 No Version Available
Previous Version No Version Available
Notes

Header

  • Updated eCQM Version Number.

    Measure Section: eCQM Version Number

    Source of Change: Standards Update

  • ​Updated Measure Developer name from 'Mathematica Policy Research' to 'Mathematica'.

    Measure Section: Measure Developer

    Source of Change: Measure Lead

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated rationale with newer studies and data.

    Measure Section: Rationale

    Source of Change: Measure Lead

  • Updated the clinical recommendation statement with newer studies and data.

    Measure Section: Clinical Recommendation Statement

    Source of Change: Measure Lead

  • Updated references.

    Measure Section: Reference

    Source of Change: Standards Update

  • Added text to identify the Quality Data Model (QDM) version used in the measure specification.

    Measure Section: Guidance

    Source of Change: Standards Update

  • Added text to indicate whether the measure is patient-based or episode-based.

    Measure Section: Guidance

    Source of Change: Standards Update

Logic

  • Streamlined the logic by using an interval for age instead of two inequalities.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Updated the logic to refer to HIV Indicators to align with the value set change 'Indicators of Human Immunodeficiency Disease (HIV)'.

    Measure Section: Denominator Exclusions

    Source of Change: Measure Lead

  • QDM v5.5 standards update: Added 'relevantDatetime' attribute to QDM datatypes. 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated Clinical Quality Language (CQL) expression to conform with the HL7 Standard: Clinical Quality Language Specification, Release 1 STU 4 (CQL 1.4).

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Updated version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-5.0.000). Updated definitions and functions in the MAT Global Common Functions Library to align with standards changes, CQL Style Guide, and to include one new function related to calculating length of hospital stays with observation stays.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set (2.16.840.1.113762.1.4.1056.54): Renamed grouping value set to Indicators of Human Immunodeficiency Virus (HIV) to clarify purpose of the value set and better align with value set content. Renamed extensional value sets (2.16.840.1.113762.1.4.1056.51, 2.16.840.1.113762.1.4.1056.52, and 2.16.840.1.113762.1.4.1056.53) within the grouping value set to clarify purpose of the value sets and better align with value set content.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Indicators of Human Immunodeficiency Virus (HIV) (2.16.840.1.113762.1.4.1056.54): Deleted 11 SNOMED CT codes (103406000, 103407009, 103408004, 103411003, 103412005, 103413000, 103414006, 165816005, 103409007, 103410002, 698703002) based on new or changed coding guidelines. Added 1 ICD-9-CM code (176.9) based on expert review and/or public feedback.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: Apr 24, 2023