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  2. CQM-1217

Need understanding for Denominator in CMS178

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Minor Minor
    • Measure
    • Nikita Kukreja
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      Thank you for your question. In the data element "urinary catheter" used in this measure, it states that if a patient is recovered in some place other than PACU, such as an ICU, and there is documentation that a catheter was placed, it must still be in place upon discharge from the recovery or PACU area. The measure developer used the facility location of ICU and PACU to represent that a patient might be recovered in the ICU as opposed to the PACU. This logic covers these scenarios. If there is a datetime stamp for the time a patient moves out of PACU level of care, the urinary catheter must still be in place after that date and time for a patient to be included in the denominator population. Please also see CQM-1311
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      Thank you for your question. In the data element "urinary catheter" used in this measure, it states that if a patient is recovered in some place other than PACU, such as an ICU, and there is documentation that a catheter was placed, it must still be in place upon discharge from the recovery or PACU area. The measure developer used the facility location of ICU and PACU to represent that a patient might be recovered in the ICU as opposed to the PACU. This logic covers these scenarios. If there is a datetime stamp for the time a patient moves out of PACU level of care, the urinary catheter must still be in place after that date and time for a patient to be included in the denominator population. Please also see CQM-1311
    • CMS178v1/NQF0453
    • High

      Denominator states:
      OR: "Occurrence A of Procedure, Performed: Indwelling urinary catheter" ends after end of "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'ICU Locations')"
      OR: "Occurrence A of Procedure, Performed: Indwelling urinary catheter" ends after end of "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Hospital Measures-PACU')

      There is no validation provided for Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'ICU Locations') and Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Hospital Measures-PACU') in the entire measure.

      Kindly suggest

            JLeflore Joelencia Leflore
            nikita.kukreja Nikita Kukreja (Inactive)
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