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  2. CQM-466

SCIP Inf 1 - Denominator exclusions for Other Surgeries day window calculations incorrect

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Fixed
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    • Tamara Bailey
    • 520.750.4324
    • Midas+
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      Thank you for calling attention to this issue. You are correct in that the logic as it is written does not accurately reflect the abstraction guidelines in the data element "Other surgeries". This logic will be corrected in SCIP Inf-1, NQF 0527 for all 8 populations/surgeries to accurately reflect the abstraction guidelines. This same logic is found in SCIP Inf-2, NQF 0528, and it will be corrected there as well. This will be corrected for the annual update for April 1.
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      Thank you for calling attention to this issue. You are correct in that the logic as it is written does not accurately reflect the abstraction guidelines in the data element "Other surgeries". This logic will be corrected in SCIP Inf-1, NQF 0527 for all 8 populations/surgeries to accurately reflect the abstraction guidelines. This same logic is found in SCIP Inf-2, NQF 0528, and it will be corrected there as well. This will be corrected for the annual update for April 1.
    • CMS171v1/NQF0527

      From the current Denominator Exclusions:

      ■OR: "Procedure, Performed: Hospital Measures-Joint Commission Evidence of a surgical procedure requiring general or neuraxial anesthesia" <= 4 day(s) starts before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG (ordinality: 'Hospital Measures - Principal')"
      ■OR: "Procedure, Performed: Hospital Measures-Joint Commission Evidence of a surgical procedure requiring general or neuraxial anesthesia" <= 4 day(s) starts after end of "Occurrence A of Procedure, Performed: Hospital measures-CABG (ordinality: 'Hospital Measures - Principal')"
      ■OR: "Device, Applied: Hospital measures-Pacemaker or implantable defibrillator device" <= 4 day(s) starts after start of "Occurrence A of Procedure, Performed: Hospital measures-CABG"
      ■OR: "Device, Applied: Hospital measures-Pacemaker or implantable defibrillator device" <= 4 day(s) starts before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG"
      ■OR: "Procedure, Performed: Hospital Measures-Pacemaker or implantable defibrillator procedure" <= 4 day(s) starts after start of "Occurrence A of Procedure, Performed: Hospital measures-CABG"
      ■OR: "Procedure, Performed: Hospital Measures-Pacemaker or implantable defibrillator procedure" <= 4 day(s) starts before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG"

      in order to match the abstraction guidelines for the "Other Surgeries" data element of the legacy measures these should read:

      ■OR: "Procedure, Performed: Hospital Measures-Joint Commission Evidence of a surgical procedure requiring general or neuraxial anesthesia" <= 4 day(s) ends before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG (ordinality: 'Hospital Measures - Principal')"
      ■OR: "Procedure, Performed: Hospital Measures-Joint Commission Evidence of a surgical procedure requiring general or neuraxial anesthesia" <= 4 day(s) starts after end of "Occurrence A of Procedure, Performed: Hospital measures-CABG (ordinality: 'Hospital Measures - Principal')"
      ■OR: "Device, Applied: Hospital measures-Pacemaker or implantable defibrillator device" <= 4 day(s) starts after end of "Occurrence A of Procedure, Performed: Hospital measures-CABG"
      ■OR: "Device, Applied: Hospital measures-Pacemaker or implantable defibrillator device" <= 4 day(s) ends before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG"
      ■OR: "Procedure, Performed: Hospital Measures-Pacemaker or implantable defibrillator procedure" <= 4 day(s) starts after end of "Occurrence A of Procedure, Performed: Hospital measures-CABG"
      ■OR: "Procedure, Performed: Hospital Measures-Pacemaker or implantable defibrillator procedure" <= 4 day(s) ends before start of "Occurrence A of Procedure, Performed: Hospital measures-CABG"

      This logic flaw is pervasive throughout the other denominator exclusions for the other surgery types as well.

            abt.associate Abt Associate (Inactive)
            tamarabailey Tamara Bailey (Inactive)
            Deborah Krauss (Inactive), Saul Kravitz (Inactive)
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