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  2. CQM-1716

Please confirm CMS91v5 measure definition for Exclusions and Exceptions

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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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      ​Thank you for your thoughtful question. For STK-4, we want everyone to be evaluated through the denominator before they are excluded. This is why this measure has the comfort measures exclusion in the Denominator Exceptions instead of in the Denominator Exclusions like the rest of the Stroke measures. Thank you for the opportunity to clarify our intent.
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      ​Thank you for your thoughtful question. For STK-4, we want everyone to be evaluated through the denominator before they are excluded. This is why this measure has the comfort measures exclusion in the Denominator Exceptions instead of in the Denominator Exclusions like the rest of the Stroke measures. Thank you for the opportunity to clarify our intent.
    • CMS91v5/NQF0437
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      Affects algorithm development/coding.
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      Affects algorithm development/coding.

      First time submitting a question.
      In the June-2015 CQM specifications of Stroke 4 (EH_CMS91v5_NQF0437_STK-4), there are no Denominator Exclusions and several Denominator Exceptions. What's really odd and inconsistent (to me) is that these seem to be reversed. For example, normally Comfort Measures is listed as an Exclusion – see Stroke 2 (EH_CMS104v4_NQF0435_STK-2) and Stroke 3 (EH_CMS71v5_NQF0436_STK-3) and Stroke 5 (EH_CMS72v4_NQF0438_STK-5), all from June-2015 specs. Why would Stroke 4 have this listed as an Exception instead? Another example is "Patients with intra-venous or intra-arterial Thrombolytic (t-PA) Therapy prior to arrival" - it's listed as an Exception in Stroke 4, but as an Exclusion in Stroke 5.
      Can someone confirm that CMS91v5 has its Denominator Exclusions and Exceptions setup correctly?

            JLeflore Joelencia Leflore
            gguidarelli Greg Guidarelli
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