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EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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Resolution: Fixed
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Minor
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None
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Tamara Bailey
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520.750.4324
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Midas+
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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.