Yes. Depending on the data generated for the mammography procedure, one procedure can be included as more than one episode in the initial population. The HEDIS MY 2025 measure specifications for DBM-E and FMA-E do not include steps to deduplicate mammography episodes where a procedure is represented multiple times in available data. For example, a mammography procedure can be represented in multiple claims (e.g., professional and facility claim) or within multiple data types (e.g., claim and clinical encounter). There are no steps in the measure specification to deduplicate across those data. Therefore, organizations reporting the measures can observe that a mammography procedure can be included as more than one episode in the initial population.
Organizations are allowed to deduplicate if there is a mechanism to confirm that the mammography procedures represented in the data represent the same episode. Please note that automated deduplication based on date of service is not appropriate as there may be multiple mammography procedures on the same day.
The DBM-E and FMA-E measures are newly introduced for HEDIS MY 2025. Organizations that participate in reporting first-year measures are appreciated. Their reported results will not be public. The first-year results are used by NCQA to identify additional measure development needs and confirm the feasibility, reliability and validity of the measures prior to moving them to public reporting status.