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CMS Measure ID:
Version:
8
NQF Number:
389
Performance/Reporting Period
2019
Description:

Percentage of patients, regardless of age, with a diagnosis of prostate cancer at low (or very low) risk of recurrence receiving interstitial prostate brachytherapy, OR external beam radiotherapy to the prostate, OR radical prostatectomy, OR cryotherapy who did not have a bone scan performed at any time since diagnosis of prostate cancer

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent pain associated with prostate cancer.
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 pain related to prostate cancer.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Pain Related to Prostate Cancer value set (2.16.840.1.113883.3.526.3.451)

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 prostate cancer diagnosis.
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 prostate cancer diagnoses.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnosis: Prostate Cancer value set (2.16.840.1.113883.3.526.3.319)

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 bone scan diagnostic imaging.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Diagnostic Study.
Inclusion Criteria: Includes only relevant concepts associated with conventional technetium-99m-MDP bone scan as well as 18F-NaF PET (or PET/CT) scan.
Exclusion Criteria: No exclusions.

Constrained to codes in the Diagnostic Study, Performed: Bone Scan value set (2.16.840.1.113883.3.526.3.320)

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

 

Direct Reference Code

Constrained to 'Gleason score in Specimen Qualitative' LOINC code

QDM Datatype and Definition (QDM Version 5.3)

Laboratory Test, Performed

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing: The Relevant Period addresses:

  • startTime – when the laboratory test is initiated (i.e., the time the specimen collection begins)
  • stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends)

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection

Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection).

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent prostate specific antigen (PSA) test.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Laboratory Test.
Inclusion Criteria: Includes only relevant concepts associated with prostate specific antigen (PSA) tests.
Exclusion Criteria: No exclusions.

Constrained to codes in the Laboratory Test, Performed: Prostate Specific Antigen Test value set (2.16.840.1.113883.3.526.3.401)

QDM Datatype and Definition (QDM Version 5.3)

Laboratory Test, Performed

Data elements that meet criteria using this datatype should document the laboratory test indicated by the QDM category and its corresponding value set was performed.

Timing: The Relevant Period addresses:

  • startTime – when the laboratory test is initiated (i.e., the time the specimen collection begins)
  • stopTime – when the laboratory test is completed (i.e., the time the specimen collection ends)

Examples:

  • Initiation of a venipuncture for a fasting blood glucose to the time venipuncture for the fasting blood glucose is completed – basically a single point in time for many specimen collections
  • Initiation of a 24-hour urine collection for measured creatinine clearance until completion of the 24-hour urine collection

Note – the time that the result report is available is a separate attribute than the time of the study (specimen collection).

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 male.
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 male gender concepts.
Exclusion Criteria: Excludes concepts representing female gender.

Constrained to codes in the Patient Characteristic Sex: Male value set (2.16.840.1.113883.3.560.100.1)

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 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 cancer staging with the intent to obtain information such as the tumor size.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure.
Inclusion Criteria: Includes only relevant concepts associated with cancer staging.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Cancer Staging value set (2.16.840.1.113883.3.526.3.1536)

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 prostate cancer treatments.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure.
Inclusion Criteria: Includes only relevant concepts associated with interstitial prostate brachytherapy, external beam radiotherapy to the prostate and radical prostatectomy.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Prostate Cancer Treatment value set (2.16.840.1.113883.3.526.3.398)

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 salvage therapy procedures.
Data Element Scope: This value set may use the Quality Data Model (QDM) category related to Procedure.
Inclusion Criteria: Includes only relevant concepts associated with salvage therapy procedures.
Exclusion Criteria: No exclusions.

Constrained to codes in the Procedure, Performed: Salvage Therapy value set (2.16.840.1.113883.3.526.3.399)

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.