A. Study your value sets and validate your value sets by selecting the appropriate expansion profile for the upcoming eCQM Annual Update; e.g., eCQM Update YYYY-MM-DD-QA Analysis. Upon validation, analyze whether you need to make changes to your value sets. If you need to make changes to listed codes or members of grouping value sets, create a new definition version.

B. View inactive/invalid codes on the value set trial expansion spreadsheet for each eCQM Measure in VSAC Collaboration during the time that eCQM Authors are updating their value sets before CMS submits the final measure packages to the VSAC Team. At the various times that CMS submits draft measure packages to the VSAC Team, the VSAC Team populates every CMS eCQM collaboration site with a value set trial expansion spreadsheet of a measure’s value set expansions based on the most recently published value set definitions expanded/calculated with the expansion profile created for the CMS eCQM Update, such as the 2024-05-02 – QA Analysis expansion profile. These value set trial expansion spreadsheets in VSAC Collaboration include code QA analysis based on the agreed-upon code system versions for the eCQM Annual Update.

Access the Value Set Trial Expansion Spreadsheets for each eCQM Measure on VSAC Collaboration

If you are a member of the eCQM Value Set Steward groups such as “MU2 Management”, “Mathematica” and “HRSA-HAB”, you can access each measure’s collaboration site in the VSAC Collaboration Management tab.

To access the spreadsheets, filter the column headers by the following:

Last Document Update: 20240501 (YYYYMMDD)
(Note that the VSAC Team will provide this date to the eCQM Managers at the various times that the VSAC Team delivers the QA information to CMS during the eCQM Annual Update season.)

You can search directly in the VSAC Collaboration Tool by measure ID (e.g., CMS104). Refer to the VSAC Collaboration Tool User’s Guide for more information.

Analyze the value set trial expansion spreadsheet for each eCQM Measure in VSAC Collaboration. Study the codes in the “Validated Code List” in the spreadsheet. The Validated Code List shows the author-defined codes (value set definition) and their validated status (active or inactive or invalid). The validated code status is based on the code system version in the expansion profile.

The inactive/invalid codes are displayed in the Validated Code List because the value sets are expanded with the eCQM expansion profile named “eCQM Update YYYY-MM-DD - QA Analysis.” This is an expansion profile requested by the eCQM Managers for this purpose during the time that eCQM Value Set Authors are working on updating their value sets before CMS sends the VSAC Team the final measure package. Study the inactive and invalid codes to determine the codes that you would like to remove and study any remapped codes that you may want to add for the eCQM Annual Update by validating the OID in VSAC Authoring.

For any remaining inactive/invalid codes that you do not remove, VSAC will automatically retain the inactive/invalid codes and apply the code system version in which the codes were last active for the final eCQM publication – these codes will appear in the Expansion List of the value set trial expansion spreadsheet for each eCQM Measure in VSAC Collaboration at the time of the final publication.

At the interim stages when Measure Developers are working on updating and finalizing value sets using the “eCQM Update YYYY-MM-DD - QA Analysis” expansion profile and the VSAC Team delivers the measure’s value set trial expansion spreadsheets, the inactive/invalid codes are dropped and will not appear in the Expansion List. To view the inactive/invalid codes in the expansion, do a trial expansion in VSAC with the expansion profile that was created for the eCQM Annual Update, e.g., eCQM Update 2024-05-02. In the trial expansion, the inactive and invalid codes will appear in the Expansion List and show as active status for the code system in which the codes were last active. This is also true for the final eCQM Annual Update publication.

C. Validate, update, save, submit, and approve your value sets by the deadline established by the CMS-created eCQM Annual Update Timeline.

D. Confirm that all eCQM value set authors’ value sets are published and are not a draft version by the time that CMS submits the final measure packages to the VSAC Team in the Spring. The eCQM Program Managers can go to My Program Releases, Program Release Items, Export Program Release Results, and Consolidated Release Results. View column E – Latest Published Definition Version or Draft Status. To view member value sets, go to column P– Grouping Value Set Member Latest Published Definition Version or Draft Status. If Draft or Proposed status is noted in either column, value set authors need to submit the value set to the steward for approval and then VSAC will publish the value set.

You may also select the Itemized Release Results (organized by measure) option under Export Program Release Results. View Column F, Latest Published Definition Version or Draft Status. To view member value sets, go to column R– Grouping Value Set Member Latest Published Definition Version or Draft Status. If Draft or Proposed status is noted in either column, value set authors need to submit the value set to the steward for approval and then VSAC will publish the value set.

E. Download Your Value Set Purpose Statements within a Release, Edit, and Bulk Update Options

In Authoring, My Value Set Definitions, select the program, “CMS eCQM and Hybrid Measure.” Select last year’s eCQM Update 2024-05-02 in the Release dropdown menu and then click Export Search Results, Purpose Statement Results to download a spreadsheet of all existing value set purpose statements for the value sets for which you have author or steward permissions. Edit your purpose statements as desired, using this downloaded spreadsheet, and save this spreadsheet to your local environment. Once you have updated your purpose statements, upload your updated spreadsheet by clicking on the Update Purpose Statements button. For more information on the purpose statement bulk upload, please see the documentation on how to download and upload edited purpose statement field information.

To make changes to purpose statements for individual value sets, edit the value set metadata screen within the VSAC Authoring Tool and save your changes before CMS sends the final measure package to the VSAC Team.

eCQM Managers can view all the purpose statements for an entire release in My Program Releases, Program Release Items, and Purpose Statements Results.

F. Check to see if all your value sets have an “Active” review status.

All value sets definitions must have an “Active” review status by the time CMS submits the final measure packages to the VSAC Team. Use these tools to assist with identifying value sets that are due for review and to be able to “Mark as Reviewed” several value sets at once.

1. Go to My Value Set Review Status in Authoring.
2. Click the value set “Due for Review” checkbox.

3. Select all of the value sets at once by clicking the checkbox on the left above the list of value sets.
4. Click the “Mark as Reviewed” button.

eCQM Managers can view all the value set definitions that are due for review in an entire release in My Program Releases. Go to My Program Releases, select a program release, and click the Value Set Review Status Report button.

Last Reviewed: October 1, 2024