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CMS Measure ID:
Version:
7
NQF Number:
2372
Performance/Reporting Period
2019
Description:

Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the left side of the body.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Anatomical Location Site.
Inclusion Criteria: Includes only relevant concepts associated with the left side of the body. This is a grouping of SNOMED CT codes.
Exclusion Criteria: Excludes concepts representing the right side of the body.

Constrained to codes in the Anatomical Location Site: Left value set (2.16.840.1.113883.3.464.1003.122.12.1036)

QDM Attribute and Definition (QDM Version 5.3)

Anatomical Location Site

The anatomical site or structure where the diagnosis/problem manifests itself (a). The anatomical site or structure that is the focus of the action represented by the datatype (b).
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the right side of the body.
Data Element Scope: This value set may use the Quality Data Model (QDM) attribute related to Anatomical Location Site.
Inclusion Criteria: Includes only relevant concepts associated with the right side of the body. This is a grouping of SNOMED CT codes.
Exclusion Criteria: Excludes concepts representing the left side of the body.

Constrained to codes in the Anatomical Location Site: Right value set (2.16.840.1.113883.3.464.1003.122.12.1035)

QDM Attribute and Definition (QDM Version 5.3)

Anatomical Location Site

The anatomical site or structure where the diagnosis/problem manifests itself (a). The anatomical site or structure that is the focus of the action represented by the datatype (b).
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a previous history of bilateral mastectomy.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with patients that have ever had a bilateral mastectomy performed. This is a grouping of SNOMED CT and ICD-10-CM codes.
Exclusion Criteria: Excludes codes that indicate a unilateral mastectomy or are unspecified.

Constrained to codes in the Diagnosis: History of bilateral mastectomy value set (2.16.840.1.113883.3.464.1003.198.12.1068)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a history of a left mastectomy.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with patients that have a history of a left mastectomy. This is a grouping of SNOMED CT and ICD-10-CM codes.
Exclusion Criteria: Excludes codes that indicate a right or bilateral mastectomy or are unspecified.

Constrained to codes in the Diagnosis: Status Post Left Mastectomy value set (2.16.840.1.113883.3.464.1003.198.12.1069)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a history of a right mastectomy.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with patients that have a history of a right mastectomy. This is a grouping of SNOMED CT and ICD-10-CM codes.
Exclusion Criteria: Excludes codes that indicate a left or bilateral mastectomy or are unspecified.

Constrained to codes in the Diagnosis: Status Post Right Mastectomy value set (2.16.840.1.113883.3.464.1003.198.12.1070)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a unilateral mastectomy where the side was not specified.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with a unilateral mastectomy performed, but the side was not specified. This is a grouping of SNOMED CT and ICD-10-CM codes.
Exclusion Criteria: Excludes codes that indicate a bilateral mastectomy or a unilateral mastectomy where the side is specified.

Constrained to codes in the Diagnosis: Unilateral Mastectomy, Unspecified Laterality value set (2.16.840.1.113883.3.464.1003.198.12.1071)

QDM Datatype and Definition (QDM Version 5.3)

Diagnosis

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The Prevalence Period references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent mammography tests.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Diagnostic Study, Performed.
Inclusion Criteria: Includes only relevant concepts associated with screening or diagnostic mammography. This is a grouping of HCPCS and LOINC codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnostic Study, Performed: Mammography value set (2.16.840.1.113883.3.464.1003.108.12.1018)

QDM Datatype and Definition (QDM Version 5.3)

Diagnostic Study, Performed

Data elements that meet criteria using this datatype should document the completion of the diagnostic study indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – when the diagnostic study is initiated
  • stopTime – when the diagnostic study is completed

Examples:

  • Initiation of a treadmill stress test to the time the treadmill stress test has completed
  • Initiation of the ultrasound study until completion of the ultrasound study

 

Value Set Description from VSAC
Clinical Focus: This value set grouping contains concepts that represent annual wellness visits.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an annual wellness visit.
Inclusion Criteria: Includes only relevant concepts associated with encounters specific to annual wellness visits.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Annual Wellness Visit 1 value set (2.16.840.1.113883.3.526.3.1240)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the most common inpatient encounter types.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Encounter. The intent of this data element is to identify patients who have had an inpatient encounter.
Inclusion Criteria: Includes only relevant concepts associated with SNOMED CT codes representing inpatient encounter.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had a home health visit by a provider for the evaluation or management of a new or existing patient.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with home visits for the evaluation and management of a new or established patient. This is a grouping value set of CPT and SNOMED CT codes.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Home Healthcare Services value set (2.16.840.1.113883.3.464.1003.101.12.1016)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients who have had an office or other outpatient visit.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with comprehensive history, evaluation, and management of a patient in an office or outpatient facility. Patient can be presenting with problems that are minor to high severity. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes non-office visits, including telehealth services.

Constrained to codes in the Encounter, Performed: Office Visit 1 value set (2.16.840.1.113883.3.464.1003.101.12.1001)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients over the age of 18 who have had an established preventive care office visit.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with comprehensive preventive medicine reevaluation and management of an individual over the age of 18. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes non-office visits, including telehealth services.

Constrained to codes in the Encounter, Performed: Preventive Care Services - Established Office Visit, 18 and Up 1 value set (2.16.840.1.113883.3.464.1003.101.12.1025)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients over the age of 18 who have had an initial preventive care office visit.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Encounter, Performed.
Inclusion Criteria: Includes only relevant concepts associated with comprehensive preventive medicine reevaluation and management of an individual over the age of 18. This is a grouping value set of CPT codes.
Exclusion Criteria: Excludes non-office visits, including telehealth services.

Constrained to codes in the Encounter, Performed: Preventive Care Services-Initial Office Visit, 18 and Up 1 value set (2.16.840.1.113883.3.464.1003.101.12.1023)

QDM Datatype and Definition (QDM Version 5.3)

Encounter, Performed

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

Timing: The Relevant Period addresses:

  • startTime – the time the encounter began (admission time)
  • stopTime – the time the encounter ended (discharge time)

The Author dateTime addresses when an Encounter is documented. Documentation can occur at the beginning, during, at the end or subsequent to the end of an Encounter. The Author dateTime should be used only if the Relevant Period cannot be obtained.

The Location Period is an attribute of the attribute facility location addresses:

  • startTime - the time the patient arrived at the location;
  • stopTime - the time the patient departed from the location

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients receiving hospice care outside of a hospital or long term care facility.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Procedure, Order or Intervention, Order. The intent of this value set is to identify all patients receiving hospice care outside of a hospital or long term care facility.
Inclusion Criteria: Includes only relevant concepts associated with hospice care concepts.
Exclusion Criteria: Excludes concepts for palliative care or comfort measures.

Constrained to codes in the Intervention, Order: Hospice care ambulatory value set (2.16.840.1.113762.1.4.1108.15)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Order

Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; Author dateTime

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent patients receiving hospice care outside of a hospital or long term care facility.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Procedure, Order or Intervention, Order. The intent of this value set is to identify all patients receiving hospice care outside of a hospital or long term care facility.
Inclusion Criteria: Includes only relevant concepts associated with hospice care concepts.
Exclusion Criteria: Excludes concepts for palliative care or comfort measures.

Constrained to codes in the Intervention, Performed: Hospice care ambulatory value set (2.16.840.1.113762.1.4.1108.15)

QDM Datatype and Definition (QDM Version 5.3)

Intervention, Performed

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the time the intervention begins
  • stopTime – the time the intervention ends

NOTE - timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent whether the patient is Hispanic or not; ethnicity category defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Ethnicity.
Inclusion Criteria: Includes only relevant concepts associated with ethnicity defined as Hispanic or Latino, or Not Hispanic or Latino.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Ethnicity: Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Ethnicity

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using Patient Characteristic, Ethnicity should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Payer.
Inclusion Criteria: Includes only relevant concepts associated with payer codes in the code system.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Payer: Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Payer

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing: The Relevant Period addresses:

  • startTime – the first day of insurance coverage with the referenced payer
  • stopTime – the last day of insurance coverage with the referenced payer

 

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent the general race category reported by the patient - subject may have more than one; defined by the Centers for Disease Control and Prevention and National Center for Health Statistics.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Race.
Inclusion Criteria: Includes only relevant concepts associated with the following race categories: American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, Other Race, White.
Exclusion Criteria: No exclusions.

Constrained to codes in the Patient Characteristic Race: Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Race

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using Patient Characteristic, Race should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent female.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes only relevant concepts associated with appropriate female gender concepts.
Exclusion Criteria: Excludes concepts representing male gender.

Constrained to codes in the Patient Characteristic Sex: Female value set (2.16.840.1.113883.3.560.100.2)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent gender identity restricted to only male and female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Patient Characteristic Sex.
Inclusion Criteria: Includes relevant concepts associated with gender concepts for male and female only.
Exclusion Criteria: Excludes any gender identity that is not male or female.

Constrained to codes in the Patient Characteristic Sex: ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition (QDM Version 5.3)

Patient Characteristic Sex

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent bilateral mastectomy procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Procedure, Performed.
Inclusion Criteria: Includes only relevant concepts associated with a bilateral mastectomy. This is a grouping of SNOMED CT codes.
Exclusion Criteria: Excludes codes that indicate a unilateral mastectomy or are unspecified.

Constrained to codes in the Procedure, Performed: Bilateral Mastectomy value set (2.16.840.1.113883.3.464.1003.198.12.1005)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.
Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent a unilateral mastectomy.
Data Element Scope: This value set may use the Quality Data Model (QDM) datatype related to Diagnosis.
Inclusion Criteria: Includes only relevant concepts associated with identifying that a unilateral mastectomy was performed. This is a grouping of SNOMED CT and ICD-10-CM codes.
Exclusion Criteria: Excludes codes that indicate a bilateral mastectomy.

Constrained to codes in the Procedure, Performed: Unilateral Mastectomy value set (2.16.840.1.113883.3.464.1003.198.12.1020)

QDM Datatype and Definition (QDM Version 5.3)

Procedure, Performed

Data elements that meet criteria using this datatype should document the completion of the procedure indicated by the QDM category and its corresponding value set.

A QDM Known Issue has been identified related to this datatype. To see this QDM known Issue, please click here.

Timing: The Relevant Period addresses:

  • startTime -the time the procedure begins,
  • stopTime -the time the procedure is completed

NOTE:

  1. Timing refers to a single instance of a procedure. If a measure seeks to evaluate multiple procedures over a period of time, the measure developer should use CQL logic to represent the query request.
  2. The Incision dateTime is a single point in time available from the Operating Room and/or Anesthesia Record.