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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Resolved
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Minor
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None
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Carla McCorkle
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520-750-4177
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Midas+
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Yes
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CMS100v3/NQF142, CMS30v4/NQF0639
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Cases with Comfort Measures Only documented during Inpatient Stay will not be excluded.
We appreciate the update to the Comfort Measure Only(CMO) logic to include CMO documented during the ED visit. However, there is a discrepancy in how the logic is written for AMI-2 and how it is written for AMI-10.
As written for AMI-2, the logic makes sense and will calculate correctly. However, for AMI-10, we believe there are conflicting statements in the ED Visit logic (additional AND statement for Encounter Inpatient). Below is how the statements appear in each:
AMI-2
OR:
AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
AMI-10
OR:
AND: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 1 hour(s) ends before start of "Occurrence A of Encounter, Performed: Encounter Inpatient"
AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts after start of "Occurrence A of Encounter, Performed: Emergency Department Visit"
AND: "Occurrence A of Intervention, Performed: Comfort Measures" starts before or during "Occurrence A of Encounter, Performed: Encounter Inpatient"
Is the intent that CMO is documented in both the ED and during the IP encounter as written in AMI-10? We suspect that the intent is to capture only CMO which starts after the start of the ED visit, as written in AMI-2. The additional logic statements will capture CMO documented during the IP encounter.
Screenshots attached for further clarification.