Draft dQM CMS Content Implementation Guide
2025.1.0 - CI Build

Draft dQM CMS Content Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2025.1.0 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/dqm-content-cms-2025/ and changes regularly. See the Directory of published versions

## Artifacts Summary

This page provides a list of the FHIR artifacts defined as part of this implementation guide.

### Knowledge Artifacts: Measure

These define measures as part of content in this implementation guide.

Breast Cancer ScreeningFHIR | Percentage of women 40-74 years of age who had a mammogram to screen for breast cancer in the 27 months prior to the end of the Measurement Period
Colorectal Cancer ScreeningFHIR | Percentage of adults 45-75 years of age who had appropriate screening for colorectal cancer
Controlling High Blood PressureFHIR | Percentage of patients 18-85 years of age who had a diagnosis of essential hypertension starting before and continuing into, or starting during the first six months of the measurement period, and whose most recent blood pressure was adequately controlled (&lt;140/90 mmHg) during the measurement period
Diabetes: Glycemic Status Assessment Greater Than 9%FHIR | Percentage of patients 18-75 years of age with diabetes who had a glycemic status assessment (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) &gt; 9.0% during the measurement period
Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults - Facility OQRFHIR | This measure is an episode of care measure that provides a standardized method for monitoring the performance of diagnostic CT to discourage unnecessarily high radiation doses, a risk factor for cancer, while preserving image quality. This measure is expressed as a percentage of CT exams that are out-of-range based on having either excessive radiation dose or inadequate image quality relative to evidence-based thresholds based on the clinical indication for the exam. All diagnostic CT exams of specified anatomic sites performed in hospital non-inpatient care settings (including emergency settings) are eligible. This dQM requires the use of additional software to access primary data elements stored within radiology electronic health records and translate them into data elements that can be ingested by this dQM. Additional details are included in the Guidance (Usage) field.
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)FHIR | Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) \<=40% who were prescribed or already taking ACE inhibitor or ARB or ARNI therapy during the measurement period
Preventive Care and Screening: Screening for Depression and Follow-Up PlanFHIR | Percentage of patients aged 12 years and older screened for depression on the date of the encounter or up to 14 days prior to the date of the encounter using an age-appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of or up to two days after the date of the qualifying encounter
Venous Thromboembolism ProphylaxisFHIR | This measure assesses the number of patients who received Venous Thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given between the day of arrival to the day after hospital admission or surgery end date for surgeries that end the day after hospital admission

### Knowledge Artifacts: Libraries

These define logic, asset collections and other libraries as part of content in this implementation guide.

AHAOverall | This version of the AHAOverall library is patterned after HFCommonDefinitionsQDM library version ‘3.0.000’
AdultOutpatientEncounters | This library contains a definition used to identify denominator qualifying encounters.
AdvancedIllnessandFrailty | This library contains definitions used to exclude patients 66 and older with an indication of frailty who also meet advanced illness criteria, and patients 66 and older who are living long term in a nursing home.
AlaraCommonFunctions | Provides common functions used in the Alara CT measures for determining qualifying scans and extracting noise and dose values.
CMS108FHIRVTEProphylaxis | CMS108FHIRVTEProphylaxis
CMS1206FHIRCTOQR | CMS1206FHIRCTOQR
CMS122FHIRDiabetesAssessGT9Pct | CMS122FHIRDiabetesAssessGT9Pct
CMS125FHIRBreastCancerScreen | CMS125FHIRBreastCancerScreen
CMS130FHIRColorectalCancerScrn | CMS130FHIRColorectalCancerScrn
CMS135FHIRACEIorARBorARNIforHF | CMS135FHIRACEIorARBorARNIforHF
CMS165FHIRControllingHighBP | CMS165FHIRControllingHighBP
CMS2FHIRPCSDepScreenAndFollowUp | CMS2FHIRPCSDepScreenAndFollowUp
CMS986FHIRMalnutritionScore | CMS986FHIRMalnutritionScore
CQMCommon | This library contains declarations that are commonly used in eCQMs and shared across the logic of multiple measures, such as the Encounter Inpatient value set, and the Inpatient Encounter population criteria definition. This library also contains functions for calculating hospitalization duration as well as hospital arrival and departure times.
Hospice | This library contains a definition used to exclude patients who are in hospice care for any part of the measurement period.
PalliativeCare | This library contains a definition used to exclude patients receiving palliative care for any part of the measurement period.
Status | This library contains functions used to constrain FHIR resource elements for measures authored by NCQA, based on QICore 6.0.0 resources including IG and authoring patterns. The functions may appear similar to some QICoreCommon functions but differ in that they have constraints that are relevant for measures authored by NCQA.
SupplementalDataElements | This is the QI-Core 6.0.0-derived version of the Supplemental Data Elements library containing the CMS SDE definitions for Payer, Race, Ethnicity and Sex
TJCOverall | Common functions and definitions used by TJC measures
US Quality Core Common | Common terminologies and functions used in US Quality Core-based CQL artifacts
VTE | Definitions and functions used for VTE measures, including VTE Initial Population.

### Other

These are resources that are used within this implementation guide that do not fit into one of the other categories.

Input Expansion Parameters | The input expansion parameters resource for this implementation guide, specifying SNOMED Edition and version. This resource will be contained within the published implementation guide with all pinned references.