We are reviewing HSR reports from reporting period 07/01/22-06/30/23 for the hybrid measures and had a question regarding the laboratory submission requirement calculation noted on TABLE III.

The submission requirements for laboratory test results references non-surgical patients.  

The Number of Total Discharges with Complete Data and the Hospital's Percentage Achieved is noted.  Could you clarify what is used for the denominator for the laboratory result calculation?  It appears the Total Discharges (based on claims) may be used, but the surgical cohort is included in this number.  

Are the surgical patients included in the Submission Requirement Percentage Achieved for laboratory tests noted on Table III:  Summary of Your Hospitals Submission of CCDE Information for the Hybrid HWR Measure?

Example:  HWR measure (please see attached visual)

Total Discharges (based on Claims) = 1504

Number of Total Discharges with Complete Data = 1304

Hospital's Percentage achieved noted 86.7%