Our hospital voluntarily submitted data for the Hybrid Readmission measure (CMS529) through our vendor (Epic). The QRDA file generated by our EHR only included patients that were 65 yrs and older. When we received the feedback report, the hospital did not fulfill the completeness requirement due to incomplete data match with claims. After review of the feedback report, the reviewers believe that the issue is that CMS is expecting all patients to be included in the QRDA file regardless of age or exclusion factors. CMS will then exclude patients from the file on their end by age and/or exclusion factors.

Should the QRDA file generated by our vendor include all patients regardless of age?