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  1. eCQM Issue Tracker
  2. CQM-6862

CMS 986 Logic Question

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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 inquiry into CMS 986, the Global Malnutrition Composite Score.

      Measure performance should range only from 0-100%. The scenario listed above provides erroneous calculations, as described in EKI-21. The measure observation logic in MO2, MO3, and MO4 is missing the requirement that the valid encounter contains a “Malnutrition Risk Screening At Risk Result” or an ordered “Hospital Dietitian Referral”. This may result in erroneously high-performance scores not aligned with measure intent or a true measurement of performance.

      While publication of the final updated AU 2024 package is pending, the QMS team worked diligently to ensure this error is corrected through a series of logic updates.
      Show
      Thank you for your inquiry into CMS 986, the Global Malnutrition Composite Score. Measure performance should range only from 0-100%. The scenario listed above provides erroneous calculations, as described in EKI-21 . The measure observation logic in MO2, MO3, and MO4 is missing the requirement that the valid encounter contains a “Malnutrition Risk Screening At Risk Result” or an ordered “Hospital Dietitian Referral”. This may result in erroneously high-performance scores not aligned with measure intent or a true measurement of performance. While publication of the final updated AU 2024 package is pending, the QMS team worked diligently to ensure this error is corrected through a series of logic updates.
    • CMS0986v2

      1) Can you confirm that the logic changes in related Jira tix below will fix the issue outlined in the example below, which we are finding resulted using v2:

      MO1: Screening completed = Not At Risk (1)

      MO2: Nutrition Assessment completed = Severely Malnourished (1)

      MO3: Malnutrition Dx = Severely Malnourished (1)

      MO4: Nutrition Care Plan of severely malnourished documented (1)

      MO5: 4

      MO6: 400% (4/1)

      Based on our understanding of the measure intent, MO6 should have a result of 100%.

      We are seeing this at many of our clients who have implemented this measure. The initial screening (MO1) is completed with a result of 'not at risk', but then a follow-up assessment is completed and indicates the patient is malnourished. This does not appear to be handled in the current logic.

      https://oncprojectracking.healthit.gov/support/browse/CQM-6095

      https://oncprojectracking.healthit.gov/support/browse/EKI-21

       

      2) Can you confirm all fixes have been implemented in v3 of the measure for 2025 measurement period?

      Thanks!

            JLeflore Joelencia Leflore
            kbeatson123 Kristen Beatson
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