| Measure Information | 2022 Performance Period |
|---|---|
| CMS eCQM ID | CMS771v3 |
| 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. 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. |
| Telehealth Eligible | No |
| Next Version | |
| Previous Version |
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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 |
*Note: There is a known issue on CMS771v3. See issue EKI-11 on the ONC eCQM Known Issues Dashboard for details.
Data Element Repository
Header
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Updated the eCQM version number.
Measure Section: eCQM Version Number
Source of Change: Annual Update
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Updated copyright.
Measure Section: Copyright
Source of Change: Annual Update
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Updated disclaimer.
Measure Section: Disclaimer
Source of Change: Annual Update
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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
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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
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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
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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
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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
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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.
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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