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  2. CQM-5777

Medication on Discharge (STK-2, STK-6)

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      ​​Thank you for your question on CMS104, Discharged on Antithrombotic Therapy and CMS105, Discharged on Statin Medication. The discharge from inpatient to inpatient rehabilitation does not disqualify the patient from being included in the stroke discharge measures (STK-2, STK-3 and STK-6).

      The “Discharge To Acute Care Facility” value set (OID 2.16.840.1.113883.3.117.1.7.1.87), currently contains discharge dispositions for the following three codes and excludes these discharges from the measure denominators.

                           306701001: Discharge to community hospital (procedure)
                           306703003: Discharge to tertiary referral hospital (procedure)
                           434781000124105: Discharge to acute care hospital (procedure)​

      However 'Discharge to rehabilitation facility' (value set below) is not in this value set. Thus, patients discharged to rehabilitation facilities are in the stroke discharge measures denominator.

                           433591000124103: Discharge to rehabilitation facility (procedure)

      You are correct. The patient was not captured by the numerator because the qualifying medication was not on the discharge medication list from the original inpatient admission.
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      ​​Thank you for your question on CMS104, Discharged on Antithrombotic Therapy and CMS105, Discharged on Statin Medication. The discharge from inpatient to inpatient rehabilitation does not disqualify the patient from being included in the stroke discharge measures (STK-2, STK-3 and STK-6). The “Discharge To Acute Care Facility” value set (OID 2.16.840.1.113883.3.117.1.7.1.87), currently contains discharge dispositions for the following three codes and excludes these discharges from the measure denominators.                      306701001: Discharge to community hospital (procedure)                      306703003: Discharge to tertiary referral hospital (procedure)                      434781000124105: Discharge to acute care hospital (procedure)​ However 'Discharge to rehabilitation facility' (value set below) is not in this value set. Thus, patients discharged to rehabilitation facilities are in the stroke discharge measures denominator.                      433591000124103: Discharge to rehabilitation facility (procedure) You are correct. The patient was not captured by the numerator because the qualifying medication was not on the discharge medication list from the original inpatient admission.
    • CMS0104v10
    • Patients being counted in numerator for metrics

      For the medication at discharge measures(STK-2, STK-6) we’re seeing some patients who are internally discharged to our Inpatient Rehab that are then prescribed qualifying medication before final discharge, these patients are not being captured in our numerator because they have a discharge from their original admission.  Within our EHR the patient have one encounter and a qualifying medication but only after they are discharged to the rehab facility.  Should we be capturing these patients in our numerator or does the discharge from inpatient to Inpatient rehab disqualify the patient from being counted in the measure?

            JLeflore Mathematica EH eCQM Team
            dglimpse David Glimpse (Inactive)
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