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  2. CQM-6131

CMS986v2 : Query Regarding Measure Observation

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      Thank you for your inquiry about CMS986v2 Global Malnutrition Composite Score (GMCS).

      Query 1: For your first question related to patient 123, the calculations listed are correct. Patients are eligible for only one “TotalMalnutritionCompositeScore as Percentage” per encounter regardless of the number of times the component is completed. As a reminder, the four components do not need to be completed sequentially. Therefore, each component receives credit for performance any time during the encounter.

      For your second question, the statement “For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period”, refers to the use of 'Average’ when a reporting facility calculates performance across a reporting period. The "TotalMalnutritionCompositeScore as Percentage" averages the GMCS for hospitalizations during the measurement period that meet the measure population (i.e., adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours) to calculate the facility’s overall GMCS measure score. This will range from 0-100%. For scenario 1, the "TotalMalnutritionCompositeScore as Percentage" calculation would be: (100% + 100% + 100%) ÷ 3 = 300% ÷ 3 = 100%.

      Query 2: For your first comment, starting January 1, 2024, the name of component 2 is “Nutrition Assessment and Identified Status”. “Malnutrition Assessment” has been removed. Please see the eCQI Resource Center (https://ecqi.healthit.gov/ecqm/eh/2024/cms0986v2) for the updated CMS986v2.

      For your last question, both episodes 4567 and 4569 are correct as provided. For 4568, the eligible denominator is 2 when a “Nutrition Assessment” is performed and a “Nutrition Assessment Status Not or Mildly Malnourished " is identified. Here, the "TotalMalnutritionCompositeScore as Percentage" calculation is 50% as the patient did not receive a malnutrition risk screening yet did receive a nutrition assessment with a mild nutrition assessment status. For patient 4568, the "TotalMalnutritionCompositeScore as Percentage" calculation would be: (0 + 1) ÷ 2 = 1 ÷ 2 = 50%.

      Please reference attached PDF to view table of calculations.
      Show
      Thank you for your inquiry about CMS986v2 Global Malnutrition Composite Score (GMCS). Query 1: For your first question related to patient 123, the calculations listed are correct. Patients are eligible for only one “TotalMalnutritionCompositeScore as Percentage” per encounter regardless of the number of times the component is completed. As a reminder, the four components do not need to be completed sequentially. Therefore, each component receives credit for performance any time during the encounter. For your second question, the statement “For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period”, refers to the use of 'Average’ when a reporting facility calculates performance across a reporting period. The "TotalMalnutritionCompositeScore as Percentage" averages the GMCS for hospitalizations during the measurement period that meet the measure population (i.e., adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours) to calculate the facility’s overall GMCS measure score. This will range from 0-100%. For scenario 1, the "TotalMalnutritionCompositeScore as Percentage" calculation would be: (100% + 100% + 100%) ÷ 3 = 300% ÷ 3 = 100%. Query 2: For your first comment, starting January 1, 2024, the name of component 2 is “Nutrition Assessment and Identified Status”. “Malnutrition Assessment” has been removed. Please see the eCQI Resource Center ( https://ecqi.healthit.gov/ecqm/eh/2024/cms0986v2 ) for the updated CMS986v2. For your last question, both episodes 4567 and 4569 are correct as provided. For 4568, the eligible denominator is 2 when a “Nutrition Assessment” is performed and a “Nutrition Assessment Status Not or Mildly Malnourished " is identified. Here, the "TotalMalnutritionCompositeScore as Percentage" calculation is 50% as the patient did not receive a malnutrition risk screening yet did receive a nutrition assessment with a mild nutrition assessment status. For patient 4568, the "TotalMalnutritionCompositeScore as Percentage" calculation would be: (0 + 1) ÷ 2 = 1 ÷ 2 = 50%. Please reference attached PDF to view table of calculations.
    • CMS0986v2

      Hi Team,

       

      Consider the below points from Rate Aggregation section:

      "Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations:

      -For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators.

      -For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period.

       

      Query 1 :

      In the excel attached we have added two scenarios out of which first scenario indicates the point 1 from the above statements. Please help us if our understanding is correct. If yes, how do we interpret point 2 from the above statements?

       

      Query 2:

      As explained in ticket CQM-5495 :- the terms of "Malnutrition Assessment" and "Nutrition Assessment" do refer to the same concept. In the next annual update, the measure will update the content and only use the term "Nutrition Assessment".

      With the above statement and the scenario 2 in attached excel Please help us understand what the output of the measure observation 6 in case of episode of care 4568 will be?

       

      Request you to provide us with the resolution urgently as our client deliverables are dependent on it.

       

        1. CMS986v2_Scenarios.xlsx
          19 kB
        2. CQM-6131 Response to Inquiry.pdf
          112 kB

            JLeflore Mathematica EH eCQM Team
            GayatriK4 gayatri kulkarni
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