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  1. eCQM Issue Tracker
  2. CQM-6490

2024 ePC-05 Specification Missing Logic for 37 Weeks of Greater EGA Based on Coding

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
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    • Elizabeth Butler
    • 8166681260
    • Oracle Health onbehalf of CommonSpirit Health System
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      Thank you for your question about CMS334v5/PC-02 Cesarean Birth and CMS1028v2/PC-07 Severe Obstetric Complications. Please submit any questions related to PC-05, PC-06, and PC-01 to The Joint Commission WIKI platform https://manual.jointcommission.org/Home.

      To provide a response to your questions for CMS334v5 and CMS1028v2:

      The codes in the value sets “37 to 42 Plus Weeks Gestation” (OID: 2.16.840.1.113762.1.4.1110.68) and “20 to 42 Plus Weeks Gestation” (OID: 2.16.840.1.113762.1.4.1110.67) cannot be used for the other measures you have flagged because they represent maternal codes (as opposed to codes for newborns). We hope this helps.
      Show
      Thank you for your question about CMS334v5/PC-02 Cesarean Birth and CMS1028v2/PC-07 Severe Obstetric Complications. Please submit any questions related to PC-05, PC-06, and PC-01 to The Joint Commission WIKI platform https://manual.jointcommission.org/Home . To provide a response to your questions for CMS334v5 and CMS1028v2: The codes in the value sets “37 to 42 Plus Weeks Gestation” (OID: 2.16.840.1.113762.1.4.1110.68) and “20 to 42 Plus Weeks Gestation” (OID: 2.16.840.1.113762.1.4.1110.67) cannot be used for the other measures you have flagged because they represent maternal codes (as opposed to codes for newborns). We hope this helps.
    • CMS0334v5, CMS1028v2
    • 2024 ePC-05 eCQM specification does not evaluate EGA at Delivery consistently with how other measure (ePC-02 and ePC-05) evaluate EGA. This could cause encounters to inappropriately show as NOT MET in the report that should be excluded.

      For 2024 TJC updated the ePC-02 and ePC-07 specifications were updated to evaluate EGA at Delivery via Diagnosis Coding. 

       

      When ePC-05 evaluates encounters for EGA >=37 weeks, it should look at coding also to be consistent with the 2024 updates on the other Perinatal Care eCQMs.

      This valueset represents EGAs at Delivery += 37 weeks.  https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1110.67/expansion/Latest) 

       

       

        1. ePC-05 2024 Specification Missing Criteria for Evaluating 37 Weeks or Greater Based on Coding.docx
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        2. TJC Website - eCQM issues to ONC Issue Tracking System.png
          TJC Website - eCQM issues to ONC Issue Tracking System.png
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            JLeflore Joelencia Leflore
            EP019624 Elizabeth Polenz
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