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Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy

Measure Information 2022 Performance Period
CMS Measure ID CMS645v5
NQF Number Not Applicable
Measure Description

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

Initial Population

Male patients with a qualifying encounter in the measurement period AND with a diagnosis of prostate cancer AND with an order for ADT or an active medication of ADT with an intent for treatment greater than or equal to 12 months during the measurement period

Denominator Statement

Equals Initial Population

Denominator Exclusions

None

Numerator Statement

Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment

Numerator Exclusions

Not Applicable

Denominator Exceptions

Patient refused recommendation for a bone density evaluation after the start of ADT therapy

Measure Steward Oregon Urology
Quality Domain Effective Clinical Care
Measure Scoring Proportion measure
Measure Type Process measure
Improvement Notation

A higher score indicates better quality

Guidance

In order to capture the practitioner's intent of androgen deprivation therapy (ADT) for a period of 12 months or greater, SNOMEDCT 456381000124102 which is Injection of leuprolide acetate for twelve month period (regime/therapy) is the correct code.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

MIPS Quality ID 462
Meaningful Measure Management of Chronic Conditions
Telehealth Eligible Yes
Next Version
Previous Version

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Measure Information 2021 Performance Period 2022 Performance Period 2023 Performance Period
CMS Measure ID CMS645v4 CMS645v5 CMS645v6
NQF Number Not Applicable Not Applicable Not Applicable
Measure Description

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

Patients determined as having prostate cancer who are currently starting or undergoing androgen deprivation therapy (ADT), for an anticipated period of 12 months or greater and who receive an initial bone density evaluation. The bone density evaluation must be prior to the start of ADT or within 3 months of the start of ADT.

Initial Population

Male patients with a qualifying encounter in the measurement period AND with a diagnosis of prostate cancer AND with an order for ADT or an active medication of ADT with an intent for treatment greater than or equal to 12 months during the measurement period

Male patients with a qualifying encounter in the measurement period AND with a diagnosis of prostate cancer AND with an order for ADT or an active medication of ADT with an intent for treatment greater than or equal to 12 months during the measurement period

Male patients with a qualifying encounter in the measurement period AND with a diagnosis of prostate cancer AND with an order for ADT or an active medication of ADT with an intent for treatment greater than or equal to 12 months during the measurement period

Denominator Statement

Equals Initial Population

Equals Initial Population

Equals Initial Population

Denominator Exclusions None None None
Numerator Statement

Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment

Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment

Patients with a bone density evaluation within the two years prior to the start of or less than three months after the start of ADT treatment

Numerator Exclusions

Not Applicable

Not Applicable

Not Applicable

Denominator Exceptions

Patient refused recommendation for a bone density evaluation after the start of ADT therapy

Patient refused recommendation for a bone density evaluation after the start of ADT therapy

Patient refused the bone density evaluation at the time ordered or did not have it performed within 3 months after the start of ADT

Measure Steward Oregon Urology Oregon Urology Oregon Urology
Quality Domain Effective Clinical Care Effective Clinical Care Effective Clinical Care
Measure Scoring Proportion measure Proportion measure Proportion measure
Measure Type Process measure Process measure Process measure
Improvement Notation

A higher score indicates better quality

A higher score indicates better quality

A higher score indicates better quality

Guidance

In order to capture the practitioner's intent of androgen deprivation therapy (ADT) for a period of 12 months or greater, SNOMEDCT 456381000124102 which is Injection of leuprolide acetate for twelve month period (regime/therapy) is the correct code.

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.

In order to capture the practitioner's intent of androgen deprivation therapy (ADT) for a period of 12 months or greater, SNOMEDCT 456381000124102 which is Injection of leuprolide acetate for twelve month period (regime/therapy) is the correct code.

This eCQM is a patient-based measure.

This version of the eCQM uses QDM version 5.5. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

In order to capture the practitioner's intent of androgen deprivation therapy (ADT) for a period of 12 months or greater, SNOMEDCT 456381000124102 which is Injection of leuprolide acetate for twelve month period (regime/therapy) is the correct code.

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 462 462 462
Meaningful Measure Management of Chronic Conditions Management of Chronic Conditions Management of Chronic Conditions
Telehealth Eligible Yes Yes Yes
Next Version CMS645v5 CMS645v6 No Version Available
Previous Version No Version Available

Release Notes

Header

  • Updated the 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

Logic

  • Added Androgen Deprivation Therapy for Urology Care Medication Order Start Dates definition, revised Androgen Deprivation Therapy for Urology Care Medication Active Start Dates definition and revised Androgen Deprivation Therapy Start Date definition, all referenced in the initial population and numerator, to account for addition of ordered medications to align with measure intent.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Changed timing in the Androgen Deprivation Therapy Start Date definition from 'overlaps' the measurement period to 'before end of' the measurement period to meet measure intent.

    Measure Section: Initial Population

    Source of Change: Expert Work Group Review

  • Updated logic from 'on or before end of' prostate cancer prevalence period to 'during' prostate cancer prevalence period in the Androgen Deprivation Therapy Start Date definition as ADT must occur during the prostate cancer prevalence period, not before.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Added Androgen Deprivation Therapy for Urology Care Medication Order Start Dates definition and revised Androgen Deprivation Therapy Start Date definition, referenced in the initial population and numerator, to account for ordered medications to align with measure intent.

    Measure Section: Numerator

    Source of Change: Measure Lead

  • Added Androgen Deprivation Therapy for Urology Care Medication Order Start Dates definition and revised Androgen Deprivation Therapy Start Date definition, referenced in the initial population and numerator, to account for ordered medications to align with measure intent.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added Androgen Deprivation Therapy for Urology Care Medication Order Start Dates definition and revised the Androgen Deprivation Therapy Start Date definition to include orders for medication.

    Measure Section: Definitions

    Source of Change: Logic Review

  • Updated logic from 'starts on or before end' of prostate cancer prevalence period to 'during' prostate cancer prevalence period in the Androgen Deprivation Therapy Start Date definition as ADT must occur during the prostate cancer prevalence period, not before.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated the names of Clinical Quality Language (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 the version number of the Measure Authoring Tool (MAT) Global Common Functions Library (MATGlobalCommonFunctions-6.2.000). Updated the 'Inpatient Encounter' definition to include a 'day of' timing clarification. Added the following timing functions: Normalize Interval, Has Start, Has End, Latest, Latest Of, Earliest, and Earliest Of. Please see individual measure details for application of specific timing functions.

    Measure Section: Multiple Sections

    Source of Change: Standards Update

  • Added new NormalizeInterval function to timing attributes to decrease implementation burden due to variable use of timing attributes for select QDM data types. The NormalizeInterval function was applied, where applicable, for the following data elements: Assessment, Performed; Device, Applied; Diagnostic Study, Performed; Intervention, Performed; Laboratory Test, Performed; Medication, Administered; Medication, Dispensed; Physical Exam, Performed; Procedure, Performed; Substance, Administered.

    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 Androgen deprivation therapy for Urology Care (2.16.840.1.113762.1.4.1151.48): Added 1 RxNorm code (314008) based on terminology update. Deleted 1 RxNorm code (571914) based on terminology update.

    Measure Section: Terminology

    Source of Change: Annual Update

Last Updated: May 04, 2022