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CMS871v2 - Help understanding the result for a specific scenario

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      ​Thank you for your inquiry on our CMS871 measure. Yes, the blood glucose value (209) on Day Index 1 is being evaluated when applying the logic - "All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL."
      Although the measure does not count any hyperglycemic events (glucose level >300) for the Numerator Measure Observation that occur in the first 24 hours as a hyperglycemic event day, the first 24 hours of the encounter is always considered dayIndex 1. This is because if there was a day during the encounter where a blood glucose test was not done, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., dayIndex 1, to be one of the preceding days. For example, if on day 3 of the encounter (dayIndex 3) there was no glucose measured, then the two preceding days, which are encounter day 2 (dayIndex 2) and encounter day 1 (dayIndex 1), are evaluated to see if they meet the >200 mg/dL criteria. So, in the scenario you provided, Numerator Measure Observations = 1 hyperglycemic event day (dayIndex 3).

      We will provide more clarity around this this in the Guidance for the next annual update, and will also change the alias of ‘dayIndex’ used in a numerous definitions to ‘dayNumber’ to better align with the intent.
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      ​Thank you for your inquiry on our CMS871 measure. Yes, the blood glucose value (209) on Day Index 1 is being evaluated when applying the logic - "All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL." Although the measure does not count any hyperglycemic events (glucose level >300) for the Numerator Measure Observation that occur in the first 24 hours as a hyperglycemic event day, the first 24 hours of the encounter is always considered dayIndex 1. This is because if there was a day during the encounter where a blood glucose test was not done, the measure evaluates the two days preceding to see if each had a glucose value >=200 mg/dL. The measure allows the first 24 hours of the encounter, i.e., dayIndex 1, to be one of the preceding days. For example, if on day 3 of the encounter (dayIndex 3) there was no glucose measured, then the two preceding days, which are encounter day 2 (dayIndex 2) and encounter day 1 (dayIndex 1), are evaluated to see if they meet the >200 mg/dL criteria. So, in the scenario you provided, Numerator Measure Observations = 1 hyperglycemic event day (dayIndex 3). We will provide more clarity around this this in the Guidance for the next annual update, and will also change the alias of ‘dayIndex’ used in a numerous definitions to ‘dayNumber’ to better align with the intent.
    • CMS0871v2

      In the example provided below, should we be evaluating the blood glucose value (209) on Day Index 1, when applying the logic - "All days where a blood glucose was not measured, and it was preceded by two consecutive days where at least one glucose value during each of the two days was >=200 mg/dL."

      Encounter start: 5/4 9am
      Encounter end: 5/7 11 am
      Relevant period: 3 days (5/4 9am to 5/7 859am)
      Denominator Observations: 2 eligible hospital days
      Numerator Observations: 1 hyperglycemic event day (dayIndex 3) ??

      dayIndex Hospitalization Periods (24 hr intervals) Eligible Days for Measure Observation Glucose Results Hyperglycemic Event Days
      1 5/4 9:00 am – 5/5 8:59 am 1st 24 hrs is not eligible 209  ** 
      2 5/5 9:00 am – 5/6 8:59 am Eligible Day 1 240  ** 
      3 5/6 9:00 am – 5/7 8:59 am Eligible Day 2  **  True

      Since the 209 value is in the first 24 hours, is it eligible for use as part of the "2 consecutive days prior to the day when no glucose test was done" in the above example?  If not, then the Day Index 3 would be false, right? Meaning, there were no hyperglycemic event days for this episode of care.

      Within the guidance section of this eCQM specification, there is statement that the blood glucose value of >300 mg/dl in the first 24 hours after admission is not evaluated, but there is no reference to whether a value of >= 200 in the first 24 hours after admission can or cannot be evaluated as part of the "2 consecutive days prior to the day when no glucose test was done"

      We would appreciate a clarification on this.

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            JLeflore Joelencia Leflore
            mparekhji Manish Parekhji
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