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  1. eCQM Issue Tracker
  2. CQM-6672

STK Comfort Measure Order for Den Exclusion

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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      Thank you for your question regarding the stroke measure STK-2 CMS104v11 Discharged on Antithrombotic Therapy (also referencing: STK-3 CMS71v12 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 CMS72v11 Antithrombotic Therapy By End of Hospital Day 2, STK-6 CMS105v11 Discharged on Statin Medication). For STK-2, 3 and 6 the patient will be excluded if comfort measures are ordered, or an intervention is performed anytime during the hospitalization. For STK-5 comfort measures ‘order’ or ‘intervention performed’ occurs “1 day or less on or after day of start of Global Hospitalization, would also meet the exclusion criteria. STK-5 looks at the date and not the time, allowing for comfort measures to occur anytime during the day of hospitalization or anytime the next day.

      The recommended documentation must be found in a discrete data field in the medical record and can be an order performed or an intervention order or intervention performed:

       •"Intervention, Order: Comfort Measures" using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)"
      •"Intervention, Performed: Comfort Measures" using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)"​

      We recommend you consult with your EHR vendor and/or clinical partners to verify that the discontinuation has removed the cited case. If mapping is conducted, you should maintain documentation in case of a CMS audit.
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      Thank you for your question regarding the stroke measure STK-2 CMS104v11 Discharged on Antithrombotic Therapy (also referencing: STK-3 CMS71v12 Anticoagulation Therapy for Atrial Fibrillation/Flutter, STK-5 CMS72v11 Antithrombotic Therapy By End of Hospital Day 2, STK-6 CMS105v11 Discharged on Statin Medication). For STK-2, 3 and 6 the patient will be excluded if comfort measures are ordered, or an intervention is performed anytime during the hospitalization. For STK-5 comfort measures ‘order’ or ‘intervention performed’ occurs “1 day or less on or after day of start of Global Hospitalization, would also meet the exclusion criteria. STK-5 looks at the date and not the time, allowing for comfort measures to occur anytime during the day of hospitalization or anytime the next day. The recommended documentation must be found in a discrete data field in the medical record and can be an order performed or an intervention order or intervention performed:  •"Intervention, Order: Comfort Measures" using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)" •"Intervention, Performed: Comfort Measures" using "Comfort Measures SNOMEDCT Value Set (1.3.6.1.4.1.33895.1.3.0.45)"​ We recommend you consult with your EHR vendor and/or clinical partners to verify that the discontinuation has removed the cited case. If mapping is conducted, you should maintain documentation in case of a CMS audit.
    • CMS0071v12

      We have a STK case that qualified for STK-2, 3, 5, and 6.  Patient was admitted on 1/12 and comfort measures were ordered on 1/13, but then discontinued on 1/14.  The patient was not discharged until 1/27.  It's not clear whether or not the discontinuation of the order affects whether or not it would count towards a denominator exclusion.  Technically, for STK-5, there was a comfort measures order in place on day 2.  For the other measures, it's our understanding that comfort measures can be ordered anytime during the encounter, but does it need to be active until discharge?

            JLeflore Joelencia Leflore
            cherman Curin Herman
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