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  1. eCQM Issue Tracker
  2. CQM-1590

CMS114 is including patients with a secondary diagnosis of VTE POA in the denominator

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
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    • Lynn Myers
    • 617-636-4826
    • Tufts Medical Center
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      Patients with a VTE present on admission should not be included in the denominator population for CMS114v3. The inclusion of such patients is achieved in two ways: 1) the initial population specifically includes patients who were diagnosed with a VTE (VTE diagnosis start datetime) during the inpatient admission; 2) the denominator exclusion logic accounts for patients who were diagnosed with VTE (diagnosis start datetime) prior to inpatient admission.

      Currently, there is no available mechanism in eCQM logic syntax to represent the concept of present on admission. The only way to express whether the diagnosis is present on admission is through timing constraints. We welcome your feedback on how we can make better use of timing constraints to exclude patients with a diagnosis present on admission
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      Patients with a VTE present on admission should not be included in the denominator population for CMS114v3. The inclusion of such patients is achieved in two ways: 1) the initial population specifically includes patients who were diagnosed with a VTE (VTE diagnosis start datetime) during the inpatient admission; 2) the denominator exclusion logic accounts for patients who were diagnosed with VTE (diagnosis start datetime) prior to inpatient admission. Currently, there is no available mechanism in eCQM logic syntax to represent the concept of present on admission. The only way to express whether the diagnosis is present on admission is through timing constraints. We welcome your feedback on how we can make better use of timing constraints to exclude patients with a diagnosis present on admission
    • CMS114v3/NQFna
    • 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.

            balu Balu Balasubramanyam (Inactive)
            lynnmyers Lynn Myers (Inactive)
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