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  2. CQM-6142

Follow up on - Global Malnutrition eCQM v2 Measure Observation 6 calculation

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    • Resolution: Answered
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    • Shravanthi S
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      Thank you for your follow up inquiry from eCQM Issue Tracker CQM-6095 for CMS986v2: Global Malnutrition Composite Score (GMCS). Please reference theCMS986v2 “Guidance” section, which specifies, “Component Measure 2: Inpatient hospitalizations for patients with a current “Nutrition Assessment” performed from a “Malnutrition Screening At Risk Result” during the current hospitalization or a “Hospital Dietitian Referral” order from a physician or eligible clinician during the current hospitalization”.

      Because the patient received a “Not At-Risk” Result from the Malnutrition Risk Screening, the composite measure calculation should be stopped at measure observation 1 with an eligible denominator of 1. The calculation should be: MO1 = 1, MO2 = 0, MO3 = 0, MO4 = 0, MO5 = 1 (1+0+0+0), MO6 = 100% (1/1). Further clarification of Measure Observation 2 will be provided in the next annual update.
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      Thank you for your follow up inquiry from eCQM Issue Tracker CQM-6095 for CMS986v2: Global Malnutrition Composite Score (GMCS). Please reference theCMS986v2 “Guidance” section, which specifies, “Component Measure 2: Inpatient hospitalizations for patients with a current “Nutrition Assessment” performed from a “Malnutrition Screening At Risk Result” during the current hospitalization or a “Hospital Dietitian Referral” order from a physician or eligible clinician during the current hospitalization”. Because the patient received a “Not At-Risk” Result from the Malnutrition Risk Screening, the composite measure calculation should be stopped at measure observation 1 with an eligible denominator of 1. The calculation should be: MO1 = 1, MO2 = 0, MO3 = 0, MO4 = 0, MO5 = 1 (1+0+0+0), MO6 = 100% (1/1). Further clarification of Measure Observation 2 will be provided in the next annual update.
    • CMS0986v2

      Hi team,

      We have few follow up questions on this ticket – https://oncprojectracking.healthit.gov/support/browse/CQM-6095

      1. The solution provided says “the calculation should be revised to the following - (MO1 = 1) + (MO2 = 0) + (MO3 = 0) + (MO4 = 0), MO5 = (1 + 0 + 0 + 0), MO6 = MO5 (1) / Eligible Denominators (1) = (1/1) = 100%”. Could you please provide more clarification on how the calculation will be revised, are the vendors supposed to make changes in the calculation or the measure specifications will be revised?
      2. The solution says – “In the scenario, the patient is not eligible for the measure observation 2 denominator as an ‘at risk of malnutrition’ result from Component 1 was not present and a ‘hospital dietitian referral’ was not ordered. Similarly, the patient was not eligible for the measure observations 3 and 4 denominator as a ‘moderately malnourished’ or ‘severely malnourished’ status identified was not present.“ According to the measure logic, if the codes 84291-4 (this code is part of both value sets: Malnutrition Risk Screening - 2.16.840.1.113762.1.4.1095.92 and Malnutrition Assessment - 2.16.840.1.113762.1.4.1095.21) and 36823005 (this code is part of both value sets: Malnutrition Screening Not At Risk Result - 2.16.840.1.113762.1.4.1095.34 and Nutrition Assessment Status Not or Mildly Malnourished - 2.16.840.1.113762.1.4.1095.48) are charted, the patient will qualify for both MO1 and MO2, since these 2 codes are part of both Screening and Assessment value sets. Find below the snippets from Bonnie tool where this scenario is replicated and MO6 is calculated to 200%. As per the MO2 logic, it does not look for hospital dietitian referral or Malnutrition Screening results, the qualification is based on Nutrition Assessment and its results only. Please help us understand how the patient will not be eligible for MO2 in this scenario as per the measure logic.
      3. We see impacts in Certification also if this scenario is not being accounted for in the measure logic. Hence, could you please clarify how the CQL logic works in this scenario.

       

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            JLeflore Mathematica EH eCQM Team
            SS056651 Shravanthi S
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