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

Measure Information	2022 Performance Period
CMS eCQM ID	CMS771v3
NQF Number	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
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
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.
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 Exceptions	None
Measure 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. 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.
MIPS Quality ID	476
Telehealth Eligible	No
Next Version	CMS771v4
Previous Version	CMS771v2

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Measure Information	2021 Performance Period	2022 Performance Period	2023 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
CMS eCQM ID	CMS771v2	CMS771v3	CMS771v4
NQF Number	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
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
Denominator	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.
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
Numerator Exclusions	Not Applicable	Not Applicable	Not Applicable
Denominator Exceptions	None	None	None
Measure Steward	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
Measure Type	Patient Reported Outcome measure	Patient Reported Outcome measure	Patient Reported Outcome Performance 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.
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.
MIPS Quality ID	476	476	476
Telehealth Eligible	No	No	No
Next Version	CMS771v3	CMS771v4	No Version Available
Previous Version	No Version Available	CMS771v2	CMS771v3

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Data Element Repository

Data Elements contained within CMS771v3

Value Sets

Value Sets to be used with CMS771v3

Release Notes

CMS771v3-TRN.xlsx

Header

Updated the eCQM version number.

Measure Section: eCQM Version Number

Source of Change: Annual Update
Updated copyright.

Measure Section: Copyright

Source of Change: Annual Update
Updated disclaimer.

Measure Section: Disclaimer

Source of Change: Annual Update
Added clarifying language to guidance section indicating that the measure is not eligible for telehealth visits.

Measure Section: Guidance

Source of Change: Measure Lead

Logic

Added new functions: Earliest, EarliestOf, and Global HasStart, to provide clarity in handling when null values arise in logic that includes an interval with either a closed or open boundary(ies).

Measure Section: Functions

Source of Change: Annual Update
Added 'sort by start of prevalence period' to the Initial BPH Diagnosis Starts Within 6 Months Before or After Start of Measurement Period definition to return the first instance of the BPH diagnosis.

Measure Section: Multiple Sections

Source of Change: ONC Project Tracking System (Jira): CQM-4063
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.

Replaced direct reference code LOINC code (88087-2) with direct reference code LOINC code (39156-5) based on review by technical experts, SMEs, and/or public feedback and to harmonize with other measures.

Measure Section: Terminology

Source of Change: Measure Lead