The Denominator of CMS188v4 (NQF 0147, PN-6) has two AND blocks that contain similar criteria but the first block contains no Occurrence qualifiers, leading to a presumably unintended outcome.

Here is the first block:

• AND:
  • AND: "Diagnosis, Active: Hospital Measures-Pneumonia"
  • AND: "Medication, Active: IV, IM, PO Antimicrobial Medications (route: 'Hospital measures-Route IV, oral or IM')"
  • <= 24 hour(s) starts after start of "Encounter, Performed: Encounter Inpatient"
• AND NOT: "Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Encounter, Performed: Encounter Inpatient"
• AND NOT: "Encounter, Performed: ICU Admission or Transfer" <= 24 hour(s) starts after start of "Encounter, Performed: Encounter Inpatient"

Because there are no Occurrence qualifiers, for any patient who has ever had an ED visit that led directly to an inpatient admission or who has ever been transferred to ICU within 24 hours of an inpatient admission, regardless of pneumonia diagnoses or medications, the corresponding "AND NOT" criterion above will be false (true from the existence of the qualifying events, negated to false by the NOT) and thus the patient will be excluded from the Denominator.

The Encounter Inpatient references within this block should be prefixed with "Occurrence A".