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  2. CQM-5644

VTE Prophylaxis under different CCN qualifying as acceptable for 'In Numerator' at second CCN

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    • Icon: EH/CAH eCQMs EH/CAH eCQMs
    • Resolution: Answered
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      ​Thank you for your comments. According to the provided scenario, Facility A is submitting one EOC under one CCN 123 and Facility B is submitting another EOC under another CCN 456. Therefore, those 2 EOCs should be evaluated separately with 2 measure results (one for each hospital) in terms of passing or failing a measure. The eCQM is an EOC based measure and Doug should not receive a ‘met’ for one EOC due to a treatment from another EOC. We recommend addressing this issue to your reporting team to find out how patient data is retrieved and connected.
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      ​Thank you for your comments. According to the provided scenario, Facility A is submitting one EOC under one CCN 123 and Facility B is submitting another EOC under another CCN 456. Therefore, those 2 EOCs should be evaluated separately with 2 measure results (one for each hospital) in terms of passing or failing a measure. The eCQM is an EOC based measure and Doug should not receive a ‘met’ for one EOC due to a treatment from another EOC. We recommend addressing this issue to your reporting team to find out how patient data is retrieved and connected.
    • Potentially reporting 'in Numerator' incorrectly

      Please see CQM-3189 as this is the same issue.. I just need to verify that not changes have been made to make this an acceptable scenario.

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      Doug is admitted to CCN: 123 from 1/2 - 1/4... he is then transferred to CCN: 456 from 1/4-1/8. These CCNs use the same EHR platform but with different FINs. Currently we our report for VTE is pulling prophylaxis done at CCN: 123 on 1/4 to meet the measure for CCN: 456 VTE prophylaxis met. This patient is showing 'In Numerator'. But first VTE prophylaxis at CCN: 456 was not documented until 1/7. 

       

      Please verify that since these are stays at two different CCNs they are considered two EOC. Therefore, prophylaxis at one facility cannot be used for the other.

       

      Thank you

      deb parnell

            JLeflore Mathematica EH eCQM Team
            Deb Parnell Deborah Parnell
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