The annual update process is usually a limited review of the precision of the measure’s specifications—completed annually (or semiannually, in some cases) in the years the measure is not undergoing Comprehensive Reevaluation. The Annual Update includes updates to the measure's code sets, which ensures updates to the quality measure’s procedure, diagnostic, and other codes (e.g., Current Procedural Terminology [CPT], International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System [ICD-10-CM/PCS], Logical Observation Identifiers Names and Codes [LOINC]) when code systems change. For more information on codes, see the Specify the Code section. This is also the time to review and address feedback received from interested parties about the measure’s specifications and feasibility. For information on the eCQM Annual Update see the Electronic Clinical Quality Measures (eCQMs) Specifications, Testing, Standards, Tools, and Community supplemental material. For information about annual updates for CMS CBE-endorsed measures, see the Partnership for Quality Measurement (PQM) Endorsement and Maintenance Guidebook.

Annual Update Procedure

There are typically seven steps in performing the annual update.

Review the Measure’s Code Systems

The measure developer reviews the code systems used by the measure to determine whether

• Addition or deletion of new codes from the code systems may affect the measure
• Codes changed affecting their usefulness within the measure

If not specified with ICD-10-CM/PCS codes, the measure developer must convert any ICD-9-CM codes in the measure to ICD-10-CM/PCS unless needed for a look-back period or historical data before October 1, 2015.

• When maintaining eCQM value sets, it is important to align with the vocabulary recommendations made by the Office of the National Coordinator for Health Information Technology in the Interoperability Standards Advisory, United States Core Data for Interoperability, and the Value Set Guidance.

Gather Information

The expectation is for the measure developer to routinely conduct environmental scans. This process includes reviewing and managing interested party comments on the quality measure, e.g., from public comments on proposed rules, and reviewing literature pertinent to the measure. The Environmental Scan Support Tool (ESST) and monthly measure scans can assist with the ongoing environmental scans. The measure developer should consider all new information during the annual update, with special consideration given to evidence of unforeseen adverse consequences or measure-related controversies. This surveillance may result in an early maintenance review by the CMS consensus-based entity (CBE).

If an interested party provides feedback and the measure developer determines the measure would only require a minor change, the measure developer should consider making the relevant minor change. If the feedback indicates a serious scientific concern with the clinical practice underlying the measure, the measure developer should consider performing an early maintenance review. The measure developer should evaluate the feasibility and impact of changing measure specifications. If feedback during the review recommends modifications, the measure developer should conduct a limited review of measure performance including

• National performance rates
• State and regional performance rates
• Variations in performance rates
• Validity of the measure and its constituent data elements
• Reliability of the measure and its constituent data elements

Determine the Recommended Disposition of the Measure

A discussion of the criteria forming the basis for the disposition decision for each measure and description of the possible outcomes is available in Measure Maintenance. See Measure Maintenance Reviews Overview for the possible dispositions and criteria used by most CMS programs. 

Implement the Disposition Action

For measures proposed for revision, suspension, removal, or retirement, the measure developer should evaluate the impact of the decision on the program using the measure when developing the implementation plan. If there are relevant regulatory or rulemaking schedules, the measure developer should include them in the implementation plan.

Consider Measures Not Stewarded by CMS

When CMS is not the measure steward (i.e., not ultimately responsible for maintaining the measure), the measure developer is responsible for monitoring the maintenance of the measure. This includes ensuring periodic revisions to the measure in response to updates in the underlying code systems (e.g., CPT, ICD-10-CM, LOINC) and ensure the measure is reevaluated in a manner consistent with (though not necessarily identical to) the reevaluation requirements discussed Comprehensive Reevaluation.

If CBE-Endorsed, Notify the CMS CBE of the Updated Measure

See the CMS CBE Endorsement and Maintenance Guidebook for the CBE’s latest procedures.

If CBE-Endorsed, Submit the CMS CBE Annual Status Report

Currently, the CMS CBE does not require an annual update. They do require submission of a status report 3 years after endorsement. See the PQM Status Report/Annual Update Form on the Submit a Measure webpage. See the CMS CBE Endorsement and Maintenance Guidebook for the CBE’s latest procedures. For measures proposed for revision, suspension, removal, or retirement, the measure developer evaluates the impact of the decision on the program using the measure.

More Information for CMS Measure Developers

Please note, the MMS Hub and Blueprint content are not CMS-specific, and the guidance is not prescriptive. CMS measure developers can find more information about measure maintenance reviews in the Blueprint Contractual Guidance and Considerations found on the Measure & Instrument Development and Support (MIDS) Library. The MIDS library is a protected website restricted to CMS and CMS MIDS contractors. MIDS developers should email MMSsupport@battelle.org to request access to the MIDS Library. Once eligibility is confirmed, the MIDS developer will receive an email with instructions on accessing the site.