Quality Measure Implementation Guide (STU4)
4.0.0 - STU4
Quality Measure Implementation Guide (STU4)
4.0.0 - STU4
This page is part of the Quality Measure STU2 for FHIR R4 Implementation Guide (v4.0.0: STU4 (v4.0.0)) based on FHIR R4. This is the current published version in its permanent home (it will always be available at this URL). For a full list of available versions, see the Directory of published versions 
| Active as of 2022-02-22 |
<Measure xmlns="http://hl7.org/fhir">
<id value="EXM125-FHIR"/>
<meta>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/proportion-measure-cqfm"/>
<profile
value="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/computable-measure-cqfm"/>
</meta>
<text>
<status value="extensions"/>
<div xmlns="http://www.w3.org/1999/xhtml">
<table class="grid dict">
<tr>
<th scope="row"><b>Id: </b></th>
<td style="padding-left: 4px;">EXM125-FHIR</td>
</tr>
<tr>
<th scope="row"><b>Download cql: </b></th>
<td style="padding-left: 4px;"><a href="Library-EXM125-FHIR.cql">EXM125-FHIR.cql</a></td>
</tr>
<tr>
<th scope="row"><b>Url: </b></th>
<td style="padding-left: 4px;"><a href="Measure-EXM125-FHIR.html">EXM125 - Breast Cancer Screening</a></td>
</tr>
<tr>
<th scope="row"><b>Version: </b></th>
<td style="padding-left: 4px;">8.0.000</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>value: </b> <span>125</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Identifier: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<b>value: </b> <span>112</span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Name: </b></th>
<td style="padding-left: 4px;">EXM125</td>
</tr>
<tr>
<th scope="row"><b>Title: </b></th>
<td style="padding-left: 4px;">EXM125 - Breast Cancer Screening</td>
</tr>
<tr>
<th scope="row"><b>Status: </b></th>
<td style="padding-left: 4px;">active</td>
</tr>
<tr>
<th scope="row"><b>Experimental: </b></th>
<td style="padding-left: 4px;">true</td>
</tr>
<tr>
<th scope="row"><b>Scoring: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Proportion </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Improvement Notation: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>Increased score indicates improvement </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Type: </b></th>
<td style="padding-left: 4px;">
<p style="margin-bottom: 5px;">
<span>process </span>
</p>
</td>
</tr>
<tr>
<th scope="row"><b>Date: </b></th>
<td style="padding-left: 4px;">2022-02-22</td>
</tr>
<tr>
<th scope="row"><b>Publisher: </b></th>
<td style="padding-left: 4px;">Clinical Quality Information WG</td>
</tr>
<tr>
<th scope="row"><b>Description: </b></th>
<td style="padding-left: 4px;"><div><p>Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Use Context: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>code</b></th><th><b>value</b></th></tr>
<tr>
<td>program</td>
<td></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Jurisdiction: </b></th>
<td style="padding-left: 25px;">US</td>
</tr>
<tr>
<th scope="row"><b>Topic: </b></th>
<td style="padding-left: 25px;">57024-2</td>
</tr>
<tr>
<th scope="row"><b>Purpose: </b></th>
<td style="padding-left: 4px;"><div><p>Women 51-74 years of age with a visit during the measurement period</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Copyright: </b></th>
<td style="padding-left: 25px;"><div><p>This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved.
The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Disclaimer: </b></th>
<td style="padding-left: 25px;"><div><p>The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND.</p>
</div></td>
</tr>
<tr>
<th scope="row"><b>Approval Date: </b></th>
<td style="padding-left: 4px;">2016-01-01</td>
</tr>
<tr>
<th scope="row"><b>Last Review Date: </b></th>
<td style="padding-left: 4px;">2016-09-01</td>
</tr>
<tr>
<th scope="row"><b>Effective Period: </b></th>
<td style="padding-left: 4px;">2018-01-01..2018-12-31</td>
</tr>
<tr>
<th scope="row"><b> Supplemental Data Elements: </b></th>
<td style="padding-left: 4px;">
SDE Ethnicity
SDE Payer
SDE Race
SDE Sex
</td>
</tr>
<tr>
<th scope="row"><b>Libraries: </b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><td><a href="Library-EXM125-FHIR.html">EXM125 - Breast Cancer Screening Library</a></td></tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Related Artifact Dependencies: </b></th>
<td style="padding-left: 4px;">
<li><a href="Library-SupplementalDataElements.html">Supplemental Data Elements Library</a></li>
<li><a href="http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1">http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1</a></li>
<li><a href="Library-MATGlobalCommonFunctions.html">MAT Global Common Functions FHIR Library</a></li>
<li><a href="Library-AdultOutpatientEncounters.html">Adult Outpatient Encounters Common Library</a></li>
<li><a href="Library-Hospice.html">Hospice FHIR Library</a></li>
<li><a href="http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709">http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709</a></li>
<li><a href="http://terminology.hl7.org/5.2.0/CodeSystem-condition-clinical.html">Condition Clinical Status Codes</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.108.12.1018/expansion">Mammography</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1001/expansion">Office Visit</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1240/expansion">Annual Wellness Visit</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1025/expansion">Preventive Care Services Established Office Visit, 18 and Up</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1023/expansion">Preventive Care Services Initial Office Visit, 18 and Up</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1016/expansion">Home Healthcare Services</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion">Payer</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion">Encounter Inpatient</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1108.15/expansion">Hospice Care Ambulatory</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1020/expansion">Unilateral Mastectomy</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1070/expansion">Status Post Right Mastectomy</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1071/expansion">Unilateral Mastectomy, Unspecified Laterality</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.122.12.1035/expansion">Right</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1069/expansion">Status Post Left Mastectomy</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.122.12.1036/expansion">Left</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1068/expansion">History of bilateral mastectomy</a></li>
<li><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1005/expansion">Bilateral Mastectomy</a></li>
</td>
</tr>
<tr>
<th scope="row"><b>Parameters:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>name</b></th><th><b>use</b></th><th><b>min</b></th><th><b>max</b></th><th><b>type</b></th></tr>
<tr>
<td>Measurement Period</td>
<td>in</td>
<td>0</td>
<td>1</td>
<td>Period</td>
</tr>
<tr>
<td>SDE Sex</td>
<td>out</td>
<td>0</td>
<td>1</td>
<td>Coding</td>
</tr>
<tr>
<td>Numerator</td>
<td>out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>Denominator</td>
<td>out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>SDE Payer</td>
<td>out</td>
<td>0</td>
<td>*</td>
<td>Resource</td>
</tr>
<tr>
<td>Initial Population</td>
<td>out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>SDE Ethnicity</td>
<td>out</td>
<td>0</td>
<td>*</td>
<td>Coding</td>
</tr>
<tr>
<td>Denominator Exclusion</td>
<td>out</td>
<td>0</td>
<td>1</td>
<td>boolean</td>
</tr>
<tr>
<td>SDE Race</td>
<td>out</td>
<td>0</td>
<td>*</td>
<td>Coding</td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>DataRequirements:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>Type</b></th><th><b>Must Support</b></th><th><b>Valueset Name</b></th><th><b>Valueset</b></th></tr>
<tr>
<td>Coverage</td>
<td>
period
type
</td>
<td>
Payer
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.114222.4.11.3591/expansion">Payer</a></td>
</tr>
<tr>
<td>Patient</td>
<td>
extension
value
url
</td>
<td>
</td>
<td></td>
</tr>
<tr>
<td>Condition</td>
<td>
code
clinicalStatus
</td>
<td>
Status Post Right Mastectomy
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1070/expansion">Status Post Right Mastectomy</a></td>
</tr>
<tr>
<td>Condition</td>
<td>
code
clinicalStatus
</td>
<td>
Status Post Left Mastectomy
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1069/expansion">Status Post Left Mastectomy</a></td>
</tr>
<tr>
<td>Condition</td>
<td>
bodySite
code
clinicalStatus
</td>
<td>
Unilateral Mastectomy, Unspecified Laterality
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1071/expansion">Unilateral Mastectomy, Unspecified Laterality</a></td>
</tr>
<tr>
<td>Condition</td>
<td>
code
clinicalStatus
onset
</td>
<td>
History of bilateral mastectomy
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1068/expansion">History of bilateral mastectomy</a></td>
</tr>
<tr>
<td>Procedure</td>
<td>
code
performed
status
</td>
<td>
Bilateral Mastectomy
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1005/expansion">Bilateral Mastectomy</a></td>
</tr>
<tr>
<td>Procedure</td>
<td>
code
performed
status
</td>
<td>
Unilateral Mastectomy
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.198.12.1020/expansion">Unilateral Mastectomy</a></td>
</tr>
<tr>
<td>Procedure</td>
<td>
code
performed
status
</td>
<td>
Hospice care ambulatory
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1108.15/expansion">Hospice Care Ambulatory</a></td>
</tr>
<tr>
<td>Encounter</td>
<td>
type
</td>
<td>
Office Visit
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1001/expansion">Office Visit</a></td>
</tr>
<tr>
<td>Encounter</td>
<td>
type
</td>
<td>
Annual Wellness Visit
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.526.3.1240/expansion">Annual Wellness Visit</a></td>
</tr>
<tr>
<td>Encounter</td>
<td>
type
</td>
<td>
Preventive Care Services - Established Office Visit, 18 and Up
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1025/expansion">Preventive Care Services Established Office Visit, 18 and Up</a></td>
</tr>
<tr>
<td>Encounter</td>
<td>
type
</td>
<td>
Preventive Care Services-Initial Office Visit, 18 and Up
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1023/expansion">Preventive Care Services Initial Office Visit, 18 and Up</a></td>
</tr>
<tr>
<td>Encounter</td>
<td>
type
</td>
<td>
Home Healthcare Services
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.101.12.1016/expansion">Home Healthcare Services</a></td>
</tr>
<tr>
<td>Encounter</td>
<td>
period
hospitalization
hospitalization.dischargeDisposition
type
status
</td>
<td>
Encounter Inpatient
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.666.5.307/expansion">Encounter Inpatient</a></td>
</tr>
<tr>
<td>ServiceRequest</td>
<td>
code
authoredOn
intent
</td>
<td>
Hospice care ambulatory
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1108.15/expansion">Hospice Care Ambulatory</a></td>
</tr>
<tr>
<td>DiagnosticReport</td>
<td>
effective
code
status
</td>
<td>
Mammography
</td>
<td><a href="https://vsac.nlm.nih.gov/valueset/2.16.840.1.113883.3.464.1003.108.12.1018/expansion">Mammography</a></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Direct Reference Codes:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr><th><b>display</b></th><th><b>code</b></th><th><b>system</b></th></tr>
<tr>
<td>Discharge to home for hospice care (procedure)</td>
<td>428361000124107</td>
<td><a href="http://hl7.org/fhir/R4/codesystem-snomedct.html">SNOMED CT (all versions)</a></td>
</tr>
<tr>
<td>Discharge to healthcare facility for hospice care (procedure)</td>
<td>428371000124100</td>
<td><a href="http://hl7.org/fhir/R4/codesystem-snomedct.html">SNOMED CT (all versions)</a></td>
</tr>
<tr>
<td></td>
<td>active</td>
<td><a href="http://terminology.hl7.org/5.2.0/CodeSystem-condition-clinical.html">Condition Clinical Status Codes</a></td>
</tr>
</table>
</td>
</tr>
<tr>
<th scope="row"><b>Logic Definitions:</b></th>
<td style="padding-left: 4px;">
<table class="grid-dict">
<tr>
<th><b>Group</b></th><th><b>Scoring</b></th><th><b>Population Criteria</b></th><th><b>Expression</b></th>
</tr>
<tr>
<td> </td>
<td>
<b>Measure scoring:</b>
<p style="margin-bottom: 5px;">
<span>Proportion</span>
</p>
</td>
<tr>
<td/>
<td/>
<td>Initial Population</td>
<td>
<pre><code class="language-cql">define "Initial Population":
Patient.gender = 'female'
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[51, 74]
and exists AdultOutpatientEncounters."Qualifying Encounters"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Numerator</td>
<td>
<pre><code class="language-cql">define "Numerator":
exists (
[DiagnosticReport: "Mammography"] Mammogram
where ( Global."Normalize Interval"(Mammogram.effective) ends 27 months or less before day of end of "Measurement Period" )
and Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }
)</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator</td>
<td>
<pre><code class="language-cql">define "Denominator":
"Initial Population"</code></pre>
</td>
</tr>
<tr>
<td/>
<td/>
<td>Denominator Exclusion</td>
<td>
<pre><code class="language-cql">define "Denominator Exclusion":
Hospice."Has Hospice"
or ( Count("Unilateral Mastectomy Procedure") = 2 )
or ( exists "Right Mastectomy" and exists "Left Mastectomy" )
or exists "History Bilateral Mastectomy"
or exists "Bilateral Mastectomy Procedure"</code></pre>
</td>
</tr>
</tr>
</table>
<table class="grid-dict">
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Sex</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Sex":
case
when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
else null
end</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>SDE Sex</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Sex":
SDE."SDE Sex"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Numerator</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Numerator":
exists (
[DiagnosticReport: "Mammography"] Mammogram
where ( Global."Normalize Interval"(Mammogram.effective) ends 27 months or less before day of end of "Measurement Period" )
and Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }
)</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>AdultOutpatientEncounters</td>
<td>Qualifying Encounters</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Qualifying Encounters":
(
[Encounter: "Office Visit"]
union [Encounter: "Annual Wellness Visit"]
union [Encounter: "Preventive Care Services - Established Office Visit, 18 and Up"]
union [Encounter: "Preventive Care Services-Initial Office Visit, 18 and Up"]
union [Encounter: "Home Healthcare Services"]
) ValidEncounter
where ValidEncounter.period during "Measurement Period"
and ValidEncounter.status = 'finished'</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Initial Population</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Initial Population":
Patient.gender = 'female'
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[51, 74]
and exists AdultOutpatientEncounters."Qualifying Encounters"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Denominator</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Denominator":
"Initial Population"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Payer</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Payer":
[Coverage: type in "Payer"] Payer
return {
code: Payer.type,
period: Payer.period
}</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>SDE Payer</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Payer":
SDE."SDE Payer"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Ethnicity</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Ethnicity":
(flatten (
Patient.extension Extension
where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'
return Extension.extension
)) E
where E.url = 'ombCategory'
or E.url = 'detailed'
return E.value as Coding</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>SDE Ethnicity</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Ethnicity":
SDE."SDE Ethnicity"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>Hospice</td>
<td>Has Hospice</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Has Hospice":
exists (
[Encounter: "Encounter Inpatient"] DischargeHospice
where DischargeHospice.status = 'finished'
and (
DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
or DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
)
and DischargeHospice.period ends during "Measurement Period"
)
or exists (
[ServiceRequest: "Hospice care ambulatory"] HospiceOrder
where HospiceOrder.intent = 'order'
and HospiceOrder.authoredOn in "Measurement Period"
)
or exists (
[Procedure: "Hospice care ambulatory"] HospicePerformed
where HospicePerformed.status = 'completed'
and Global."Normalize Interval"(HospicePerformed.performed) overlaps "Measurement Period"
)</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Unilateral Mastectomy Procedure</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Unilateral Mastectomy Procedure":
[Procedure: "Unilateral Mastectomy"] UnilateralMastectomyProcedure
where Global."Normalize Interval"(UnilateralMastectomyProcedure.performed) ends before day of end of "Measurement Period"
and UnilateralMastectomyProcedure.status = 'completed'</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Right Mastectomy</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Right Mastectomy":
(
( [Condition: "Status Post Right Mastectomy"] C
where C.clinicalStatus ~ ToConcept(Global."active")
)
union (
[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
where UnilateralMastectomyDiagnosis.bodySite in "Right"
and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
)
) RightMastectomy
where Global."Normalize Interval"(RightMastectomy.onset) starts before day of end of "Measurement Period"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Left Mastectomy</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Left Mastectomy":
(
( [Condition: "Status Post Left Mastectomy"] C
where C.clinicalStatus ~ ToConcept(Global."active")
)
union (
[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
where UnilateralMastectomyDiagnosis.bodySite in "Left"
and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
)
) LeftMastectomy
where Global."Normalize Interval"(LeftMastectomy.onset) starts before day of end of "Measurement Period"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>History Bilateral Mastectomy</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "History Bilateral Mastectomy":
[Condition: "History of bilateral mastectomy"] BilateralMastectomyHistory
where Global."Normalize Interval"(BilateralMastectomyHistory.onset) starts before day of end of "Measurement Period"
and BilateralMastectomyHistory.clinicalStatus ~ ToConcept(Global."active")</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Bilateral Mastectomy Procedure</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Bilateral Mastectomy Procedure":
[Procedure: "Bilateral Mastectomy"] BilateralMastectomyPerformed
where Global."Normalize Interval"(BilateralMastectomyPerformed.performed) ends before day of end of "Measurement Period"
and BilateralMastectomyPerformed.status = 'completed'</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>Denominator Exclusion</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "Denominator Exclusion":
Hospice."Has Hospice"
or ( Count("Unilateral Mastectomy Procedure") = 2 )
or ( exists "Right Mastectomy" and exists "Left Mastectomy" )
or exists "History Bilateral Mastectomy"
or exists "Bilateral Mastectomy Procedure"</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>SupplementalDataElements</td>
<td>SDE Race</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Race":
(flatten (
Patient.extension Extension
where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'
return Extension.extension
)) E
where E.url = 'ombCategory'
or E.url = 'detailed'
return E.value as Coding</code></pre></td>
</tr>
<tr><th><b>Library Name</b></th><th><b>Name</b></th></tr>
<tr>
<td>EXM125-FHIR</td>
<td>SDE Race</td>
</tr>
<tr>
<td></td>
<td><pre class="highlight language-cql"><code class="language-cql">define "SDE Race":
SDE."SDE Race"</code></pre></td>
</tr>
</table>
</td>
</tr>
</table>
</div>
</text>
<contained>
<Library>
<id value="effective-data-requirements"/>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system value="http://snomed.info/sct"/>
<version
value="http://snomed.info/sct/731000124108/version/201709"/>
<code value="428361000124107"/>
<display value="Discharge to home for hospice care (procedure)"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system value="http://snomed.info/sct"/>
<version
value="http://snomed.info/sct/731000124108/version/201709"/>
<code value="428371000124100"/>
<display
value="Discharge to healthcare facility for hospice care (procedure)"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-directReferenceCode">
<valueCoding>
<system
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
<code value="active"/>
</valueCoding>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Sex"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Sex":
case
when Patient.gender = 'male' then Code { code: 'M', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Male' }
when Patient.gender = 'female' then Code { code: 'F', system: 'http://hl7.org/fhir/v3/AdministrativeGender', display: 'Female' }
else null
end"/>
</extension>
<extension url="displaySequence">
<valueInteger value="0"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Sex"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Sex":
SDE."SDE Sex""/>
</extension>
<extension url="displaySequence">
<valueInteger value="1"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Numerator"/>
</extension>
<extension url="statement">
<valueString
value="define "Numerator":
exists (
[DiagnosticReport: "Mammography"] Mammogram
where ( Global."Normalize Interval"(Mammogram.effective) ends 27 months or less before day of end of "Measurement Period" )
and Mammogram.status in { 'final', 'amended', 'corrected', 'appended' }
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="2"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="AdultOutpatientEncounters"/>
</extension>
<extension url="name">
<valueString value="Qualifying Encounters"/>
</extension>
<extension url="statement">
<valueString
value="define "Qualifying Encounters":
(
[Encounter: "Office Visit"]
union [Encounter: "Annual Wellness Visit"]
union [Encounter: "Preventive Care Services - Established Office Visit, 18 and Up"]
union [Encounter: "Preventive Care Services-Initial Office Visit, 18 and Up"]
union [Encounter: "Home Healthcare Services"]
) ValidEncounter
where ValidEncounter.period during "Measurement Period"
and ValidEncounter.status = 'finished'"/>
</extension>
<extension url="displaySequence">
<valueInteger value="3"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Initial Population"/>
</extension>
<extension url="statement">
<valueString
value="define "Initial Population":
Patient.gender = 'female'
and Global."CalendarAgeInYearsAt"(FHIRHelpers.ToDate(Patient.birthDate), start of "Measurement Period") in Interval[51, 74]
and exists AdultOutpatientEncounters."Qualifying Encounters""/>
</extension>
<extension url="displaySequence">
<valueInteger value="4"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Denominator"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator":
"Initial Population""/>
</extension>
<extension url="displaySequence">
<valueInteger value="5"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Payer"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Payer":
[Coverage: type in "Payer"] Payer
return {
code: Payer.type,
period: Payer.period
}"/>
</extension>
<extension url="displaySequence">
<valueInteger value="6"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Payer"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Payer":
SDE."SDE Payer""/>
</extension>
<extension url="displaySequence">
<valueInteger value="7"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Ethnicity"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Ethnicity":
(flatten (
Patient.extension Extension
where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-ethnicity'
return Extension.extension
)) E
where E.url = 'ombCategory'
or E.url = 'detailed'
return E.value as Coding"/>
</extension>
<extension url="displaySequence">
<valueInteger value="8"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Ethnicity"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Ethnicity":
SDE."SDE Ethnicity""/>
</extension>
<extension url="displaySequence">
<valueInteger value="9"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="Hospice"/>
</extension>
<extension url="name">
<valueString value="Has Hospice"/>
</extension>
<extension url="statement">
<valueString
value="define "Has Hospice":
exists (
[Encounter: "Encounter Inpatient"] DischargeHospice
where DischargeHospice.status = 'finished'
and (
DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
or DischargeHospice.hospitalization.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)"
)
and DischargeHospice.period ends during "Measurement Period"
)
or exists (
[ServiceRequest: "Hospice care ambulatory"] HospiceOrder
where HospiceOrder.intent = 'order'
and HospiceOrder.authoredOn in "Measurement Period"
)
or exists (
[Procedure: "Hospice care ambulatory"] HospicePerformed
where HospicePerformed.status = 'completed'
and Global."Normalize Interval"(HospicePerformed.performed) overlaps "Measurement Period"
)"/>
</extension>
<extension url="displaySequence">
<valueInteger value="10"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Unilateral Mastectomy Procedure"/>
</extension>
<extension url="statement">
<valueString
value="define "Unilateral Mastectomy Procedure":
[Procedure: "Unilateral Mastectomy"] UnilateralMastectomyProcedure
where Global."Normalize Interval"(UnilateralMastectomyProcedure.performed) ends before day of end of "Measurement Period"
and UnilateralMastectomyProcedure.status = 'completed'"/>
</extension>
<extension url="displaySequence">
<valueInteger value="11"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Right Mastectomy"/>
</extension>
<extension url="statement">
<valueString
value="define "Right Mastectomy":
(
( [Condition: "Status Post Right Mastectomy"] C
where C.clinicalStatus ~ ToConcept(Global."active")
)
union (
[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
where UnilateralMastectomyDiagnosis.bodySite in "Right"
and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
)
) RightMastectomy
where Global."Normalize Interval"(RightMastectomy.onset) starts before day of end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="12"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Left Mastectomy"/>
</extension>
<extension url="statement">
<valueString
value="define "Left Mastectomy":
(
( [Condition: "Status Post Left Mastectomy"] C
where C.clinicalStatus ~ ToConcept(Global."active")
)
union (
[Condition: "Unilateral Mastectomy, Unspecified Laterality"] UnilateralMastectomyDiagnosis
where UnilateralMastectomyDiagnosis.bodySite in "Left"
and UnilateralMastectomyDiagnosis.clinicalStatus ~ ToConcept(Global."active")
)
) LeftMastectomy
where Global."Normalize Interval"(LeftMastectomy.onset) starts before day of end of "Measurement Period""/>
</extension>
<extension url="displaySequence">
<valueInteger value="13"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="History Bilateral Mastectomy"/>
</extension>
<extension url="statement">
<valueString
value="define "History Bilateral Mastectomy":
[Condition: "History of bilateral mastectomy"] BilateralMastectomyHistory
where Global."Normalize Interval"(BilateralMastectomyHistory.onset) starts before day of end of "Measurement Period"
and BilateralMastectomyHistory.clinicalStatus ~ ToConcept(Global."active")"/>
</extension>
<extension url="displaySequence">
<valueInteger value="14"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Bilateral Mastectomy Procedure"/>
</extension>
<extension url="statement">
<valueString
value="define "Bilateral Mastectomy Procedure":
[Procedure: "Bilateral Mastectomy"] BilateralMastectomyPerformed
where Global."Normalize Interval"(BilateralMastectomyPerformed.performed) ends before day of end of "Measurement Period"
and BilateralMastectomyPerformed.status = 'completed'"/>
</extension>
<extension url="displaySequence">
<valueInteger value="15"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="Denominator Exclusion"/>
</extension>
<extension url="statement">
<valueString
value="define "Denominator Exclusion":
Hospice."Has Hospice"
or ( Count("Unilateral Mastectomy Procedure") = 2 )
or ( exists "Right Mastectomy" and exists "Left Mastectomy" )
or exists "History Bilateral Mastectomy"
or exists "Bilateral Mastectomy Procedure""/>
</extension>
<extension url="displaySequence">
<valueInteger value="16"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="SupplementalDataElements"/>
</extension>
<extension url="name">
<valueString value="SDE Race"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Race":
(flatten (
Patient.extension Extension
where Extension.url = 'http://hl7.org/fhir/us/core/StructureDefinition/us-core-race'
return Extension.extension
)) E
where E.url = 'ombCategory'
or E.url = 'detailed'
return E.value as Coding"/>
</extension>
<extension url="displaySequence">
<valueInteger value="17"/>
</extension>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-logicDefinition">
<extension url="libraryName">
<valueString value="EXM125-FHIR"/>
</extension>
<extension url="name">
<valueString value="SDE Race"/>
</extension>
<extension url="statement">
<valueString
value="define "SDE Race":
SDE."SDE Race""/>
</extension>
<extension url="displaySequence">
<valueInteger value="18"/>
</extension>
</extension>
<name value="EffectiveDataRequirements"/>
<status value="active"/>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/library-type"/>
<code value="module-definition"/>
</coding>
</type>
<date value="2022-02-22T10:37:03-07:00"/>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library SDE"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/SupplementalDataElements|2.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library FHIRHelpers"/>
<resource
value="http://fhir.org/guides/cqf/common/Library/FHIRHelpers|4.0.1"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Global"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/MATGlobalCommonFunctions|5.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library AdultOutpatientEncounters"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/AdultOutpatientEncounters|2.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Library Hospice"/>
<resource
value="http://hl7.org/fhir/us/cqfmeasures/Library/Hospice|2.0.000"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Code system SNOMEDCT:2017-09"/>
<resource
value="http://snomed.info/sct|http://snomed.info/sct/731000124108/version/201709"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Code system ConditionClinicalStatusCodes"/>
<resource
value="http://terminology.hl7.org/CodeSystem/condition-clinical"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Mammography"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Office Visit"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Annual Wellness Visit"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Preventive Care Services - Established Office Visit, 18 and Up"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Preventive Care Services-Initial Office Visit, 18 and Up"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Home Healthcare Services"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Payer"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Encounter Inpatient"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Hospice care ambulatory"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Unilateral Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Status Post Right Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display
value="Value set Unilateral Mastectomy, Unspecified Laterality"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Right"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1035"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Status Post Left Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Left"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.122.12.1036"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set History of bilateral mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068"/>
</relatedArtifact>
<relatedArtifact>
<type value="depends-on"/>
<display value="Value set Bilateral Mastectomy"/>
<resource
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005"/>
</relatedArtifact>
<parameter>
<name value="Measurement Period"/>
<use value="in"/>
<min value="0"/>
<max value="1"/>
<type value="Period"/>
</parameter>
<parameter>
<name value="SDE Sex"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="Coding"/>
</parameter>
<parameter>
<name value="Numerator"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="Denominator"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="SDE Payer"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Resource"/>
</parameter>
<parameter>
<name value="Initial Population"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="SDE Ethnicity"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Coding"/>
</parameter>
<parameter>
<name value="Denominator Exclusion"/>
<use value="out"/>
<min value="0"/>
<max value="1"/>
<type value="boolean"/>
</parameter>
<parameter>
<name value="SDE Race"/>
<use value="out"/>
<min value="0"/>
<max value="*"/>
<type value="Coding"/>
</parameter>
<dataRequirement>
<type value="Coverage"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Coverage"/>
<mustSupport value="period"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.114222.4.11.3591"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Patient"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Patient"/>
<mustSupport value="extension"/>
<mustSupport value="value"/>
<mustSupport value="url"/>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1070"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1069"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="bodySite"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1071"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Condition"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Condition"/>
<mustSupport value="code"/>
<mustSupport value="clinicalStatus"/>
<mustSupport value="onset"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1068"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1005"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.198.12.1020"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Procedure"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Procedure"/>
<mustSupport value="code"/>
<mustSupport value="performed"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1001"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.526.3.1240"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1025"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1023"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="type"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.101.12.1016"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="Encounter"/>
<profile value="http://hl7.org/fhir/StructureDefinition/Encounter"/>
<mustSupport value="period"/>
<mustSupport value="hospitalization"/>
<mustSupport value="hospitalization.dischargeDisposition"/>
<mustSupport value="type"/>
<mustSupport value="status"/>
<codeFilter>
<path value="type"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.666.5.307"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="ServiceRequest"/>
<profile
value="http://hl7.org/fhir/StructureDefinition/ServiceRequest"/>
<mustSupport value="code"/>
<mustSupport value="authoredOn"/>
<mustSupport value="intent"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113762.1.4.1108.15"/>
</codeFilter>
</dataRequirement>
<dataRequirement>
<type value="DiagnosticReport"/>
<profile
value="http://hl7.org/fhir/StructureDefinition/DiagnosticReport"/>
<mustSupport value="effective"/>
<mustSupport value="code"/>
<mustSupport value="status"/>
<codeFilter>
<path value="code"/>
<valueSet
value="http://cts.nlm.nih.gov/fhir/ValueSet/2.16.840.1.113883.3.464.1003.108.12.1018"/>
</codeFilter>
</dataRequirement>
</Library>
</contained>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-populationBasis">
<valueCode value="boolean"/>
</extension>
<extension
url="http://hl7.org/fhir/us/cqfmeasures/StructureDefinition/cqfm-effectiveDataRequirements" id="effective-data-requirements">
<valueReference>
<reference value="#effective-data-requirements"/>
</valueReference>
</extension>
<url value="http://hl7.org/fhir/us/cqfmeasures/Measure/EXM125-FHIR"/>
<identifier>
<use value="official"/>
<system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/cms"/>
<value value="125"/>
</identifier>
<identifier>
<use value="official"/>
<system value="http://example.org/fhir/cqi/ecqm/Measure/Identifier/mips"/>
<value value="112"/>
</identifier>
<version value="8.0.000"/>
<name value="EXM125"/>
<title value="EXM125 - Breast Cancer Screening"/>
<status value="active"/>
<experimental value="true"/>
<date value="2022-02-22"/>
<publisher value="Clinical Quality Information WG"/>
<contact>
<telecom>
<system value="url"/>
<value value="http://www.hl7.org/Special/committees/cqi"/>
</telecom>
</contact>
<description
value="Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer"/>
<useContext>
<code>
<system
value="http://terminology.hl7.org/CodeSystem/usage-context-type"/>
<code value="program"/>
</code>
<valueCodeableConcept>
<coding>
<system
value="http://hl7.org/fhir/us/cqfmeasures/CodeSystem/quality-programs"/>
<code value="ep-ec"/>
<display value="EP/EC"/>
</coding>
</valueCodeableConcept>
</useContext>
<jurisdiction>
<coding>
<system value="urn:iso:std:iso:3166"/>
<code value="US"/>
</coding>
</jurisdiction>
<purpose
value="Women 51-74 years of age with a visit during the measurement period"/>
<copyright
value="This Physician Performance Measure (Measure) and related data specifications were developed by the National Committee for Quality Assurance (NCQA). The Measure is copyrighted but can be reproduced and distributed, without modification, for noncommercial purposes (eg, use by healthcare providers in connection with their practices) without obtaining approval from NCQA. Commercial use is defined as the sale, licensing, or distribution of the Measure for commercial gain, or incorporation of the Measure into a product or service that is sold, licensed or distributed for commercial gain. All commercial uses must be approved by NCQA and are subject to a license at the discretion of NCQA. NCQA is not responsible for any use of the Measure. NCQA makes no representations, warranties, or endorsement about the quality of any organization or physician that uses or reports performance measures and NCQA has no liability to anyone who relies on such measures or specifications. (C) 2012-2017 National Committee for Quality Assurance. All Rights Reserved.
Limited proprietary coding is contained in the Measure specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets. NCQA disclaims all liability for use or accuracy of any CPT or other codes contained in the specifications.
CPT(R) contained in the Measure specifications is copyright 2004-2016 American Medical Association. LOINC(R) copyright 2004-2016 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2016 International Health Terminology Standards Development Organisation. ICD-10 copyright 2016 World Health Organization. All Rights Reserved.
The American Hospital Association holds a copyright to the National Uniform Billing Committee (NUBC) codes contained in the measure specifications. The NUBC codes in the specifications are included with the permission of the AHA. The NUBC codes contained in the specifications may be used by health plans and other health care delivery organizations for the purpose of calculating and reporting Measure results or using Measure results for their internal quality improvement purposes. All other uses of the NUBC codes require a license from the AHA. Anyone desiring to use the NUBC codes in a commercial product to generate Measure results, or for any other commercial use, must obtain a commercial use license directly from the AHA. To inquire about licensing, contact ub04@healthforum.com."/>
<approvalDate value="2016-01-01"/>
<lastReviewDate value="2016-09-01"/>
<effectivePeriod>
<start value="2018-01-01"/>
<end value="2018-12-31"/>
</effectivePeriod>
<topic>
<coding>
<system value="http://loinc.org"/>
<code value="57024-2"/>
<display value="Health Quality Measure Document"/>
</coding>
</topic>
<library value="http://hl7.org/fhir/us/cqfmeasures/Library/EXM125-FHIR"/>
<disclaimer
value="The performance Measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications. THE MEASURE AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND."/>
<scoring>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-scoring"/>
<code value="proportion"/>
<display value="Proportion"/>
</coding>
</scoring>
<type>
<coding>
<system value="http://terminology.hl7.org/CodeSystem/measure-type"/>
<code value="process"/>
</coding>
</type>
<rationale
value="Breast cancer is one of the most common types of cancers, accounting for a quarter of all new cancer diagnoses for women in the U.S. (BreastCancer.Org, 2011). It ranks as the second leading cause of cancer-related mortality in women, accounting for nearly 40,000 estimated deaths in 2013 (American Cancer Society, 2011).
According to the National Cancer Institute's Surveillance Epidemiology and End Results program, the chance of a woman being diagnosed with breast cancer in a given year increases with age. By age 30, it is one in 2,212. By age 40, the chances increase to one in 235, by age 50, it becomes one in 54, and, by age 60, it is one in 25. From 2004 to 2008, the median age at the time of breast cancer diagnosis was 61 years among adult women (Tangka et al, 2010).
In the U.S., costs associated with a diagnosis of breast cancer range from $451 to $2,520, factoring in continued testing, multiple office visits, and varying procedures. The total costs related to breast cancer add up to nearly $7 billion per year in the U.S., including $2 billion spent on late-stage treatment (Lavigne et al, 2008; Boykoff et al, 2009)."/>
<clinicalRecommendationStatement
value="The U.S. Preventive Services Task Force (USPSTF) recommends biennial screening mammography for women aged 50-74 years (B recommendation). The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms (C recommendation). The Task Force concludes the evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years and older (I statement).
U.S. Preventive Services Task Force (2009)
Grade: B recommendation. The USPSTF recommends biennial screening mammography for women aged 50 to 74 years.
Grade: C recommendation. The decision to start regular, biennial screening mammography before the age of 50 years should be an individual one and take patient context into account, including the patient's values regarding specific benefits and harms.
Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of screening mammography in women 75 years or older.
Grade: D recommendation. The USPSTF recommends against teaching breast self-examination (BSE).
Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.
Grade: I Statement. The USPSTF concludes that the current evidence is insufficient to assess the additional benefits and harms of either digital mammography or magnetic resonance imaging (MRI) instead of film mammography as screening modalities for breast cancer."/>
<improvementNotation>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-improvement-notation"/>
<code value="increase"/>
<display value="Increased score indicates improvement"/>
</coding>
</improvementNotation>
<guidance
value="Patient self-report for procedures as well as diagnostic studies should be recorded in 'Procedure, Performed' template or 'Diagnostic Study, Performed' template in QRDA-1. Patient self-report is not allowed for laboratory tests.
This measure evaluates primary screening. Do not count biopsies, breast ultrasounds, MRIs or tomosynthesis (3D mammography), because they are not appropriate methods for primary breast cancer screening."/>
<group>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="initial-population"/>
<display value="Initial Population"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Initial Population"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="numerator"/>
<display value="Numerator"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Numerator"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator"/>
<display value="Denominator"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator"/>
</criteria>
</population>
<population>
<code>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-population"/>
<code value="denominator-exclusion"/>
<display value="Denominator Exclusion"/>
</coding>
</code>
<criteria>
<language value="text/cql-identifier"/>
<expression value="Denominator Exclusion"/>
</criteria>
</population>
</group>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Ethnicity"/>
</criteria>
</supplementalData>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Payer"/>
</criteria>
</supplementalData>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Race"/>
</criteria>
</supplementalData>
<supplementalData>
<usage>
<coding>
<system
value="http://terminology.hl7.org/CodeSystem/measure-data-usage"/>
<code value="supplemental-data"/>
</coding>
</usage>
<criteria>
<language value="text/cql-identifier"/>
<expression value="SDE Sex"/>
</criteria>
</supplementalData>
</Measure>
IG © 2019+ Clinical Quality Information WG. Package hl7.fhir.us.cqfmeasures#4.0.0 based on FHIR 4.0.1. Generated 2023-08-28
Links: Table of Contents |
QA Report
| Version History |
|
Propose a change