eCQM Content CMS Implementation Guide
2025.7.1 - CI Build

eCQM Content CMS Implementation Guide, published by cqframework. This guide is not an authorized publication; it is the continuous build for version 2025.7.1 built by the FHIR (HL7® FHIR® Standard) CI Build. This version is based on the current content of https://github.com/cqframework/ecqm-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

Cervical Cancer ScreeningFHIR

Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: - Women age 21-64 who had cervical cytology performed within the last 3 years - Women age 30-64 who had cervical human papillomavirus (HPV) testing performed within the last 5 years

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 (<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]) > 9.0% during the measurement period

Hospital Harm - Postoperative Respiratory FailureFHIR

This measure assesses the number of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF)

Hospital Harm - Severe HypoglycemiaFHIR

The measure assesses the number of inpatient hospitalizations for patients age 18 and older who were administered at least one hypoglycemic medication during the encounter, who suffer the harm of a severe hypoglycemic event during the encounter

Hospital Harm – Falls with InjuryFHIR

This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older

NHSN Glycemic Control Hypoglycemia Initial Population

All inpatient encounters (including ED/Observation visits that end within 1 hour of the start of the inpatient encounter) for patients of all ages where at least one diabetes medication was ordered or administered during the encounter that is 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

Safe Use of Opioids - Concurrent PrescribingFHIR

Proportion of inpatient hospitalizations for patients 18 years of age and older prescribed, or continued on, two or more opioids or an opioid and benzodiazepine concurrently at discharge

Knowledge Artifacts: Libraries

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

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.

CMS1017FHIRHHFI

CMS1017FHIRHHFI

CMS1218FHIRHHRF

CMS1218FHIRHHRF

CMS122FHIRDiabetesAssessGreaterThan9Percent

CMS122FHIRDiabetesAssessGreaterThan9Percent

CMS124FHIRCervicalCancerScreening

CMS124FHIRCervicalCancerScreening

CMS125FHIRBreastCancerScreening

CMS125FHIRBreastCancerScreening

CMS130FHIRColorectalCancerScreening

CMS130FHIRColorectalCancerScreening

CMS165FHIRControllingHighBloodPressure

CMS165FHIRControllingHighBloodPressure

CMS2FHIRPCSDepressionScreenAndFollowUp

CMS2FHIRPCSDepressionScreenAndFollowUp

CMS506FHIRSafeUseofOpioids

CMS506FHIRSafeUseofOpioids

CMS816FHIRHHHypo

CMS816FHIRHHHypo

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.

CumulativeMedicationDuration

This library provides cumulative medication duration calculation logic for use with FHIR medication prescription, administration, and dispensing resources. The logic here follows the guidance provided as part of the 5.6 version of Quality Data Model.

FHIRHelpers

This library defines functions to convert between FHIR data types and CQL system-defined types, as well as functions to support FHIRPath implementation. For more information, the FHIRHelpers wiki page: https://github.com/cqframework/clinical_quality_language/wiki/FHIRHelpers

Hospice

This library contains a definition used to exclude patients who are in hospice care for any part of the measurement period.

NHSNGlycemicControlHypoglycemiaInitialPopulation

NHSNGlycemicControlHypoglycemiaInitialPopulation

NHSNHelpers

NHSNHelpers

PalliativeCare

This library contains a definition used to exclude patients receiving palliative care for any part of the measurement period.

QICoreCommon

Common terminologies and functions used in QI-Core-based CQL artifacts

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 version of the Supplemental Data Elements library containing the CMS SDE definitions for Payer, Race, Ethnicity and Sex

eCQM FHIR Update 2025

eCQM FHIR Update 2025