Eligible Clinician eCQMs

2023 Performance Period Eligible Clinician Resources for eCQMs

eCQM Resources	Short Description	Published
Implementation Checklist eCQM Annual Update	Implementation checklist The eCQM Implementation Checklist provides the necessary technical steps health information technology developers, implementers, and healthcare organizations must take to update their systems and processes with the eCQM Annual Update for the upcoming reporting and performance periods. The most recent eCQM Annual Update should be applied to your system for use in electronic quality reporting.	--
Telehealth Guidance for eCQMs for Eligible Clinician 2023 Quality Reporting	List of eCQMs eligible clinicians can use for a telehealth visit This document provides supplemental information related to the allowance of telehealth encounters for eligible clinician eCQMs.	Nov 2022
Guide for Reading eCQMs v8.0	Assists implementers and measured entities with how to read eCQM specifications The Guide for Reading eCQMs is a resource to assist stakeholders in interpreting and understanding eCQMs. The guide provides information on eCQMs such as file naming conventions, understanding an eCQM human-readable rendition, value sets, QDM data criteria, and more.	May 2022
Eligible Clinicians Table of eCQMs	List of eCQMs available for use This table contains a list of eCQMs that are to be used to electronically report clinical quality measure data to CMS for a given quality program’s performance period.	Nov 2022
eCQM Specifications for Eligible Clinicians	eCQM technical specifications This zip file contains individual zip files for each eCQM that may be used to report clinical quality measure data to CMS. Each individual zip file contains html, xml, cql, and json technical specifications for use with a specific eCQM version for a given quality program’s performance period.	Nov 2022
Measure Authoring Tool (MAT) Global Common Library (GCL) Technical Specifications and Technical Release Notes	MAT-CGL specifications and technical release notes This zip file contains the MAT GCL html, xml, cql and json files for use with eCQMs and the technical release notes which provide an overview of technical changes, e.g., logic and terminology for a given quality program's reporting period.	May 2022
eCQM and Hybrid Measure Value Sets	Value sets used with eCQMs and Hybrid Measures The eCQM and hybrid measure value sets specify terminology codes such as ICD-10-CM/PCS, CPT, SNOMED CT, required for use with each eCQM or hybrid measure.	May 2022
eCQM Direct Reference Codes List	eCQM Direct Reference Codes used in eCQMs The eCQM Direct Reference Codes list is a list of direct reference codes (DRCs) used in eCQMs for a given quality program’s performance period. These codes are referenced directly in eCQM logic to describe a data element or one of its attributes. The list includes the description of the code, the code system from which the code is derived, and the version of that code system.	May 2022
Binding Parameter Specification (BPS) (ZIP)	Value set metadata The value set Binding Parameter Specification (BPS) is a record of the value set metadata that defines the code lists specified by current CMS eCQMs. Measure implementers and vendors use the BPS to track versions and other parameters that define the code lists for each eCQM Annual Update year.	May 2022
eCQM Logic and Implementation Guidance v6.0	Assists implementers and measured entities with how to use eCQMs and report issues The eCQM Logic and Implementation Guidance is a resource document that provides guidance for understanding, using, and/or implementing eCQMs.	May 2022
Technical Release Notes	Year over year changes to eCQM logic and terminology The Technical Release Notes are resource files which provide an overview of technical changes, e.g., logic and terminology, to each eCQM in the most recent eCQM Annual Update for CMS performance/reporting periods.	Nov 2022
Technical Release Notes	Year over year changes to eCQM logic and terminology The Technical Release Notes are resource files which provide an overview of technical changes, e.g., logic and terminology, to each eCQM in the most recent eCQM Annual Update for CMS performance/reporting periods.	Nov 2022
Standards and tool versions used for performance period	Tools and standards versions measure developers used to create eCQMs and versions of standards and tools used for their reporting The standards and tools versions listed for each reporting/performance period are the versions used to create and/or support the implementation of the specific performance period specifications.	May 2022
eCQM Flows	Assists implementers and measured entities with steps to take to calculate an eCQM The eCQM flows provide a graphical and narrative description of the descisions to calculate an eCQM performance rate.	Nov 2022
2023 Quality Benchmarks	What CMS uses to calculate MIPS measure scores Quality measure benchmarks are the point of comparison CMS uses to score the measures eligible clinicians submit. When eligible clinicians submit measures for the Merit-Based Incentive Payment System (MIPS) Quality performance category, the eligible clinician's performance on each measure is assessed against its benchmark to determine how many points the measure earns.	Feb 2023
2023 CMS QRDA III Implementation Guide for Eligible Clinicians	Format for reporting eCQMs to CMS The CMS Quality Reporting Document Architecture (QRDA) III Implementation Guide for Eligible Clinicians constrains the HL7 QRDA Category III Implementation Guide (HL7 QRDA III IG). The CMS QRDA Category III IG is used for reporting aggregated quality measure data to CMS. Note: IGs, Schematrons and sample files may be updated after initial publication to address stakeholder or policy requirements. Revisit the eCQI Resource Center for updated resources prior to use.	Dec 2022
2023 CMS QRDA III Schematrons and Sample Files	Rules to validate eCQM reports with samples The CMS Quality Reporting Document Architecture (QRDA) III Schematrons and Sample Files provide technical guidance for implementing the HL7 QRDA III standard for reporting aggregate data to CMS quality programs. The Schematron files contain a list of rules used to validate that generated QRDA III reports conform to the requirements specified in the Implementation Guides. Note: IGs, Schematrons and sample files may be updated after initial publication to address stakeholder or policy requirements. Revisit the eCQI Resource Center for updated resources prior to use.	Feb 2024
eCQM Annual Update Pre-Publication Document	Standards and code system versions for the eCQM Annual Update The eCQM Annual Update Pre-Publication Document describes the versions of the standards and code systems used in conjunction with the updated eCQMs for potential use in the Centers for Medicare & Medicaid Services (CMS) programs for the 2023 reporting/performance period. It is designed to help health information technology/electronic health record developers, Eligible Clinicians, and Eligible Hospitals/Critical Access Hospitals prepare for 2023 reporting through transparent pre-release of the expected standards and code system versions	Mar 2022

The 2023 Performance Period has 47 Eligible Clinician eCQMs:

Title	CMS eCQM ID	CBE ID*	MIPS Quality ID	Telehealth Eligible	Notes
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment	CMS161v11	0104e	107	Yes
Anti-depressant Medication Management	CMS128v11	Not Applicable	009	Yes
Appropriate Testing for Pharyngitis	CMS146v11	Not Applicable	066	Yes
Appropriate Treatment for Upper Respiratory Infection (URI)	CMS154v11	Not Applicable	065	Yes
Appropriate Use of DXA Scans in Women Under 65 Years Who Do Not Meet the Risk Factor Profile for Osteoporotic Fracture	CMS249v5	3475e	472	Yes
Bone density evaluation for patients with prostate cancer and receiving androgen deprivation therapy	CMS645v6	Not Applicable	462	Yes
Breast Cancer Screening	CMS125v11	Not Applicable	112	Yes
Cataracts: 20/40 or Better Visual Acuity within 90 Days Following Cataract Surgery	CMS133v11	0565e	191	No
Cervical Cancer Screening	CMS124v11	Not Applicable	309	Yes
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment	CMS177v11	1365e	382	Yes
Childhood Immunization Status	CMS117v11	Not Applicable	240	Yes	There is a known issue on CMS117v11. See issue EKI-27 on the ONC eCQM Known Issues Dashboard for details.
Children Who Have Dental Decay or Cavities	CMS75v11	Not Applicable	378	No
Chlamydia Screening in Women	CMS153v11	Not Applicable	310	Yes
Closing the Referral Loop: Receipt of Specialist Report	CMS50v11	Not Applicable	374	Yes
Colorectal Cancer Screening	CMS130v11	Not Applicable	113	Yes
Controlling High Blood Pressure	CMS165v11	Not Applicable	236	Yes
Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF less than or equal to 40%)	CMS145v11	0070e	007	Yes
Dementia: Cognitive Assessment	CMS149v11	2872e	281	Yes
Depression Remission at Twelve Months	CMS159v11	0710e	370	Yes
Diabetes: Eye Exam	CMS131v11	Not Applicable	117	Yes
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)	CMS122v11	Not Applicable	001	Yes
Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care	CMS142v11	Not Applicable	019	No
Documentation of Current Medications in the Medical Record	CMS68v12	Not Applicable	130	Yes
Falls: Screening for Future Fall Risk	CMS139v11	Not Applicable	318	Yes
Follow-Up Care for Children Prescribed ADHD Medication (ADD)	CMS136v12	Not Applicable	366	Yes
Functional Status Assessment for Total Hip Replacement	CMS56v11	Not Applicable	376	Yes
Functional Status Assessments for Heart Failure	CMS90v12	Not Applicable	377	Yes
Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) or Angiotensin Receptor-Neprilysin Inhibitor (ARNI) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CMS135v11	0081e	005	Yes
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	CMS144v11	0083e	008	Yes
HIV Screening	CMS349v5	Not Applicable	475	Yes
Initiation and Engagement of Substance Use Disorder Treatment	CMS137v11	Not Applicable	305	Yes
Intravesical Bacillus-Calmette-Guerin for non-muscle invasive bladder cancer	CMS646v3	Not Applicable	481	No
Kidney Health Evaluation	CMS951v1	Not Applicable	488	Yes
Oncology: Medical and Radiation - Pain Intensity Quantified	CMS157v11	0384e	143	Yes
Pneumococcal Vaccination Status for Older Adults	CMS127v11	Not Applicable	111	Yes	Only used as part of the MVP reporting and not for traditional MIPS There is a known issue on CMS127v11. See issue EKI-15 on the ONC eCQM Known Issues Dashboard for details.
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	CMS69v11	Not Applicable	128	No
Preventive Care and Screening: Influenza Immunization	CMS147v12	0041e	110	Yes	Only used as part of the MVP reporting and not for traditional MIPS
Preventive Care and Screening: Screening for Depression and Follow-Up Plan	CMS2v12	Not Applicable	134	Yes
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	CMS22v11	Not Applicable	317	No
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	CMS138v11	0028e	226	Yes
Primary Caries Prevention Intervention as Offered by Dentists	CMS74v12	Not Applicable	379	No
Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation	CMS143v11	0086e	012	No
Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients	CMS129v12	0389e	102	No
Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	CMS347v6	Not Applicable	438	Yes
Urinary Symptom Score Change 6-12 Months After Diagnosis of Benign Prostatic Hyperplasia	CMS771v4	Not Applicable	476	No
Use of High-Risk Medications in Older Adults	CMS156v11	Not Applicable	238	Yes	There is a known issue on CMS156v11. See issue EKI-17 on the ONC eCQM Known Issues Dashboard for details.
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents	CMS155v11	Not Applicable	239	Yes

Each year, CMS updates the electronic clinical quality measures (eCQMs) for potential use in CMS quality reporting programs and publishes them on the eCQI Resource Center. CMS updates the specifications annually to align with current clinical guidelines and code systems so they remain relevant and actionable within the clinical care setting. CMS requires the use of the most current version of the eCQMs as specified and intended for the applicable performance periods for all quality reporting programs.

The updated eCQMs are to be used by eligible clinicians to electronically report 2023 clinical quality measure data for CMS quality reporting programs. CMS defines the performance period for eligible clinicians as the measure data capture period of the calendar year between January 1 and December 31.

Questions related to eCQM specifications, logic, data elements, standards, or resources can be submitted in the eCQM Tracker - ONC Project Tracking System (Jira).

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