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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Answered
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Minor
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Lynn Myers
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617-636-4826
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Tufts Medical Center
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CMS114v3/NQFna
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Inappropriate patients are being included in the measure population for Preventable VTE, which makes the measure rate erroneously high.
eCQM 114 Incidence of Potentially-Preventable VTE, the denominator exclusions include patients with VTE present at admission. The population criteria say AND NOT diagnosis active:VTE (ordinality: Principal). However, we are consistently seeing cases with a secondary diagnosis code of VTE with a Present on Admission (POA) indicator of Yes being included in the denominator. In some cases even when there is also a Principal diagnosis of VTE! In looking at the QDM Elements, it looks like there is no mechanism to account for POA.