The intent of the denominator exclusion is to exclude patients with multiple fractures (including trauma) at the time of Total hip/knee arthroplasty, or patients with severe cognitive impairment. We understand your concern with a diagnosis not having a time component. During the 2017 maintenance cycle, we will update the operator to "starts after or concurrent with start of" as per your recommendation​

CMS56v4 and CMS66v4 Fracture have similar logic. We find it difficult to meet the intent of the measure with the current exclusion logic. In Centricity EMR, Diagnosis and procedures are typically recorded with day granularity, thus if a procedure is performed on the same day as the fractures, the patient is not excluded. Even though there are 0 days (<1) between start of the diagnosis and start of the procedure, because they don't have a time component, they are concurrent. It would be more clear implement the exclusions as follows Denominator Exclusions = OR: Count >= 2 of: "Diagnosis, Active: Fracture - Lower Body" satisfies all < 1 day(s) starts before start or concurrent with Occurrence A of $PrimaryTKAprocedure (There is no need for the overlap condition, though it is not a problem) Please elaborate on the intent of the exclusion, provide implementation guidance with regard to time granularity and consider changing the measure logic to support concurrent condition.

Issue Description:   We find it difficult to meet the intent of the measure with the current exclusion logic. In Centricity EMR, Diagnosis and procedures are typically recorded with day granularity, thus if a procedure is performed on the same day as the fractures, the patient is not excluded. Even though there are 0 days (<1) between start of the diagnosis and start of the procedure, because they don't have a time component, they are concurrent. It would be more clear implement the exclusions as follows Denominator Exclusions = OR: Count >= 2 of: "Diagnosis, Active: Fracture - Lower Body" satisfies all < 1 day(s) starts before start or concurrent with Occurrence A of $PrimaryTKAprocedure (There is no need for the overlap condition, though it is not a problem) Please elaborate on the intent of the exclusion, provide implementation guidance with regard to time granularity and consider changing the measure logic to support concurrent condition.   Change Description:   Often time-stamps are not attached to procedures and diagnosis. Therefore, there are scenarios in which a diagnosis/procedure performed on the 1st day of the measurement year or the last day of the year are not captured by simply using 'starts before start of' or 'starts before end of.' We propose replacing these with 'starts before or concurrent with start of' or 'starts before or concurrent with end of' respectively. For example, in CMS65, the new logic for the blood pressure visit would be:   ◦AND: First: ◾"Occurrence A of Encounter, Performed: Blood Pressure Visit" satisfies all: ◾< 6 month(s) starts after or concurrent with start of "Measurement Period" ◾overlaps "Diagnosis: Essential Hypertension" ◾overlaps "Physical Exam, Performed: Systolic Blood Pressure (result)" This change will be made across multiple measures ​

We willl replace these with 'starts before or concurrent with start of' or 'starts before or concurrent with end of' respectively. For example, in CMS66, the new logic for the blood pressure visit would be: ◾◾OR: Count>= 2 :   ◾"Diagnosis: Fracture - Lower Body" satisfies all:     ◾< 1 day(s) starts before or concurrrent with start of Occurrence A of $PrimaryTKAprocedure     ◾overlaps Occurrence A of $PrimaryTKAprocedure     ◾OR: "Diagnosis: Severe Dementia" overlaps "Measurement Period"   This change will be made across multiple measures (see CMS section number above).