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CMS Measure ID: CMS68v9    Performance/Reporting Period: 2020    Version: 9    NQF Number: 0419e
Description:

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Data Elements contained within the eCQM + Expand all

Value Set Description from VSAC
Clinical Focus: This value set contains concepts that represent multiple types of encounters that include documentation of current medications.
Data Element Scope: This value set may use the Quality Data Model (QDM) category or attribute related to Encounter.
Inclusion Criteria: Includes only relevant concepts associated with identifying types of encounters associated with documentation of medications reviewed, updated or transcribed as the current medication list.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter, Performed: Medications Encounter Code Set value set (2.16.840.1.113883.3.600.1.1834)

QDM Datatype and Definition (QDM Version 5.4)

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.

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 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
Direct Reference Code

Constrained to 'Birth date' LOINC code

QDM Datatype and Definition (QDM Version 5.4)

Patient Characteristic Birthdate

The Patient Characteristic Birthdate data element should document the patient’s date of birth. Timing: The Patient Characteristic, Birthdate is a single point in time representing the date and time of birth. It does not have a start and stop time. Note: Patient Characteristic Birthdate is fixed to LOINC code 21112-8 (Birth date) and therefore cannot be further qualified with a value set.

Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

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 5.4)

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: Categories of types of health care payor entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

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 5.4)

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: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

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 5.4)

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: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: 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 5.4)

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.

Direct Reference Code

Constrained to 'Documentation of current medications (procedure)' SNOMEDCT code

QDM Datatype and Definition (QDM Version 5.4)

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.