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OQR eCQMs
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Resolution: Answered
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Moderate
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None
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None
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Exclude PCI procedures from being counted as a "Major Surgical Procedure" if it started after ED Arrival.
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CMS0996v4
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Patients are being excluded from the denominator when the admission order is written after the PCI procedure is performed. These excluded patients would have otherwise met the measure/been in the numerator.
We have numerous examples of patients who have been excluded from the denominator for "Major Surgical Procedure 21 Days or Less Before End of ED Encounter" where the only procedure performed during that timeframe is the PCI for the STEMI from the current encounter.
Patient Excluded Example #1:
ED Arrival: 1044 am
PCI Start: 11:19AM
Balloon time: 11:34 am
Admission Order: 1211
Patient Excluded Example #2:
ED Arrival: 1552
PCI Start: 1650
Balloon time: 1705
Admission Order: 1710
We believe if the goal of the measure is reperfusion within 90 min (PCI) it should measure 90 min from ED Arrival to PCI regardless of whether the PCI occurred on the ED encounter or the IP Encounter.