We have a question regarding clause ‘Denominator Exception’, in measure CMS144 and CMS145. Below is the portion of the clause that we are seeking clarification for.
• OR:
o AND: MOST RECENT: “Occurrence B of Physical Exam, Finding: Heart Rate" starts before start of "Occurrence A of Physical Exam, Finding: Heart Rate"
o AND:
 OR:
 AND: "Occurrence A of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"
 AND: "Occurrence B of Physical Exam, Finding: Heart Rate (result < 50 bpm)" during "Occurrence A of Encounter, Performed: Care Services in Long-Term Residential Facility"

The objective of the first AND clause seems to identify a pair of Physician Exams, finding: Heart Rate, that are consecutive i.e. there is no occurrence of Physical Exam, Finding: Heart Rate between occurrence A and occurrence B. This clause has no additional constraint and hence the comparison must be done between any two occurrences of Physical Exam, Finding: Heart Rate to determine if they are consecutive or not. Please confirm.

The objective of the second AND clause seems to be straight forward that out of the selected pairs of occurrence A and occurrence B, a pair must occur during the same Encounter, Performed element and that both instances must have a result < 50 bmp to qualify for the exception. Please indicate if there is any misunderstanding on our part in understanding the clause.