Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia

Measure Information	2021 Performance Period
CMS eCQM ID	CMS771v2
NQF Number	Not Applicable
MIPS Quality ID	476
Description	Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points
Initial Population	Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to, or during the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period
Numerator	Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period
Numerator Exclusions	Not Applicable
Denominator	Equals Initial Population
Denominator Exclusions	Patients with urinary retention that starts within 1 year of initial BPH diagnosis. Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization. Patients with a diagnosis of morbid obesity, or with a BMI Exam >40 before the follow up urinary symptom score.
Denominator Exceptions	None
Steward	Large Urology Group Practice Association (LUGPA)
Measure Scoring	Proportion measure
Measure Type	Patient Reported Outcome measure
Improvement Notation	A meaningful improvement is a negative 3-point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition.
Guidance	The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30-day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions. 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	No
Next Version	CMS771v3
Previous Version	No Version Available

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Measure Information	2021 Performance Period	2022 Performance Period	2023 Performance Period	2024 Performance Period
Title	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia
CMS eCQM ID	CMS771v2	CMS771v3	CMS771v4	CMS771v5
NQF Number	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Description	Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points	Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points	Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points	Percentage of patients with an office visit within the measurement period and with a new diagnosis of clinically significant Benign Prostatic Hyperplasia who have International Prostate Symptoms Score (IPSS) or American Urological Association (AUA) Symptom Index (SI) documented at time of diagnosis and again 6-12 months later with an improvement of 3 points
Initial Population	Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to, or during the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period	Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to, or during the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period	Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to, or during the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period	Male patients with an initial diagnosis of benign prostatic hyperplasia 6 months prior to the measurement period, and a urinary symptom score assessment within 1 month of initial diagnosis and a follow-up urinary symptom score assessment within 6-12 months, who had a qualifying visit during the measurement period
Denominator	Equals Initial Population	Equals Initial Population	Equals Initial Population	Equals Initial Population
Denominator Exclusions	Patients with urinary retention that starts within 1 year of initial BPH diagnosis. Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization. Patients with a diagnosis of morbid obesity, or with a BMI Exam >40 before the follow up urinary symptom score.	Patients with urinary retention that starts within 1 year of initial BPH diagnosis. Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization. Patients with a diagnosis of morbid obesity, or with a BMI Exam >40 before the follow up urinary symptom score.	Patients with urinary retention that starts within 1 year of initial BPH diagnosis. Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization. Patients with a diagnosis of morbid obesity, or with a BMI Exam >=40 before the follow up urinary symptom score.	Patients with urinary retention that starts within 1 year of initial BPH diagnosis Patients with an initial BPH diagnosis that starts during, or within 30 days of hospitalization Patients with a diagnosis of morbid obesity, or with a BMI Exam >=40 before the follow up urinary symptom score
Numerator	Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period	Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period	Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period	Patients with a documented improvement of at least 3 points in their urinary symptom score during the measurement period
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None	None
Measure Steward	Large Urology Group Practice Association (LUGPA)	Large Urology Group Practice Association (LUGPA)	Large Urology Group Practice Association (LUGPA)	Large Urology Group Practice Association (LUGPA)
Measure Scoring	Proportion measure	Proportion measure	Proportion measure	Proportion measure
Measure Type	Patient Reported Outcome measure	Patient Reported Outcome measure	Patient Reported Outcome Performance measure	Pro-Pm measure
Improvement Notation	A meaningful improvement is a negative 3-point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition.	A meaningful improvement is a negative 3-point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition.	A meaningful improvement is a negative 3-point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition.	A meaningful improvement is a negative 3-point change in the urinary symptom score. The quality improves when a higher proportion of people meet the meaningful improvement definition.
Guidance	The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30-day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions. 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.	The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30-day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center for more information on the QDM.	The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30-day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.	The IPSS is inclusive of the symptom index score and the quality of life score. The AUA-SI is the symptom index score alone and must be added to the QOL score. The AUA-SI with the QOL equals the IPSS. Both of these are the urinary symptom score. The patient must have a urinary symptom score (USS) within 1 month after initial diagnosis. If more than one USS in the initial one month, then the first USS counts. The patient must have a USS again at 6-12 months after the initial diagnosis and if more than one USS in this time frame, then the last USS counts. The result of the test is a numeric value that relates to a continuous numeric scale. Reported either as an integer, a ratio, a real number, or a range. The test result value may optionally contain a relational operator from the set {<=, <, >, >=}. Valid values for a quantitative test are of the form “7”, “-7”, “7.4”, “-7.4”, “7.8912”, “0.125”, “<10”, “<10.15”, “>12000”, 1-10, 1:256. Hospitalization within 30 days of Initial BPH Diagnosis refers to a 30-day period between the end of the hospitalization and the clinical office setting BPH diagnosis. This is due to aggravating factors from hospitalization, such as bed rest, medications, surgery, and altered body functions. This eCQM is a patient-based measure. Telehealth encounters are not eligible for this measure because the measure requires a clinical action that cannot be conducted via telehealth. 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	476	476	476	476
Telehealth Eligible	No	No	No	No
Next Version	CMS771v3	CMS771v4	CMS771v5	No Version Available
Previous Version	No Version Available	CMS771v2	CMS771v3	CMS771v4

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CMS771v2-TRN.xlsx

Header

Changed measure title to shorten.

Measure Section: eCQM Title

Source of Change: Measure Lead
Updated eCQM Version Number.

Measure Section: eCQM Version Number

Source of Change: Standards Update
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Standards Update
Updated measure type.

Measure Section: Measure Type

Source of Change: Measure Lead
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
Added hyphen to 30-day phrase in Guidance to standardize language.

Measure Section: Guidance

Source of Change: Measure Lead
Changed numerator exclusions from 'None' to 'Not Applicable' to harmonize with other measures.

Measure Section: Numerator Exclusions

Source of Change: Expert Work Group Review

Logic

Updated the denominator exclusion logic to require proper information return (is not null) in the definition.

Measure Section: Denominator Exclusions

Source of Change: Measure Lead
Changed name of definition used in the denominator exclusions from 'Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to 'Has Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to indicate return of a Boolean response.

Measure Section: Definitions

Source of Change: Measure Lead
Changed alias to 'AUASIAssessment' and 'LastAUASI'. The alias for the primary retrieve (first line of expression) is different than the alias used within the 'LastAUASIOnDate' variable to allow the last AUASI to return for each day that there was an AUASI performed. The 'LastAUASIOnDate' will always be the last AUASI. This accommodates a situation where there may be more than one Urinary Symptom Score in a day to force the last score to count.

Measure Section: Definitions

Source of Change: Measure Lead
Updated Documented IPSS Assessment Result definition to make the definition cleaner and to align with Clinical Quality Language (CQL) Style Guide.

Measure Section: Definitions

Source of Change: Measure Lead
Added new definition 'Has Qualifying BPH diagnosis' to streamline initial population logic.

Measure Section: Definitions

Source of Change: Measure Lead
Changed definition title from 'Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to 'Has Initial BPH Diagnosis Starts During or Within 30 Days After End of Hospitalization' to reflect a Boolean return type.

Measure Section: Definitions

Source of Change: Measure Lead
Updated Initial BPH Diagnosis Within 6 Months Before or After Start of Measurement Period Prevalence Period definition by adding 'First' to capture a first diagnosis in the event of more than one diagnosis.

Measure Section: Definitions

Source of Change: Measure Lead
Added starts on or before timing to the Morbid Obesity Diagnosis On or Before Follow Up USS Assessment definition to enable an ongoing diagnosis of morbid obesity.

Measure Section: Definitions

Source of Change: Measure Lead
Changed definition title from Urinary Symptom Score to Urinary Symptom Score Tuple Return to align with the CQL Style Guide.

Measure Section: Definitions

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 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

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 Morbid Obesity (2.16.840.1.113762.1.4.1164.67): Added Morbid Obesity grouping value set based on terminology updates and to better align with measure intent. The grouping value set includes the ICD-10-CM value set used in the prior version of the measure, Morbid Obesity (2.16.840.1.113762.1.4.1164.65), plus a SNOMED CT value set, Morbid Obesity (2.16.840.1.113762.1.4.1164.66), containing 2 SNOMED CT codes (238136002, 408512008).

Measure Section: Terminology

Source of Change: Annual Update