In reviewing the results from our voluntary submission of the hybrid measure, CMS 529, we found that our hospitals were not meeting the requirement for submitting the patient weight on 90 percent of patients. We are concerned as the period for mandatory reporting starts on July 1, 2023. It seems probable that many hospitals are having the same issues. Does failure to meet the requirements for submitting vital signs on 90 % of patients mean that the hospital fails the measure?

Many of the QRDA files that we submitted for our surgical hospital did not contain the patient weight, when the weight was obtained in pre procedure testing for scheduled surgery. The measure logic exempts surgical patients from the requirement for submitting labs obtained in time period bracketing hospital admission. The measure logic recognizes that the labs were probably taken in pre procedure testing. Would it be appropriate to also include the patient weight as a data element that is exempt from the requirement for vital sign reporting for surgical patients? 

Failure to capture the weight is also an issue for patients who are initially admitted with observation status, and then changed to inpatient status after more than 24 hours. Our clinicians take the patient weight when the patient arrives at the hospital. The report requirement states that the weight be taken in the 26 hour period, 24 hours before or 2 hours after inpatient admission. Does this time period apply to when the patients are assigned inpatient status? Would it be possible to define the time period for taking the vital signs around admission to observation status to capture weights that are taken when a patient is admitted with observation status?