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  2. CQM-6982

EGA documentation for CMS334v5

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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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    • Tammy Hert
    • 8143335748
    • Meadville Medical Center
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      Thank you for inquiring about CMS334/PC-02 Cesarean Birth.
      The logic looks for the last Estimated Gestational Age (EGA) assessed in a discrete (codified) field. If the nurse completed the patient care assessment form (or flowsheet) by selecting '39 weeks' in a discrete field, and that assessment shows a date and time of 2/28/24 at 08:02 (equal to the delivery date/time) even though the nurse entered the information into the system at 08:15, the last EGA assessed is 39 weeks. The measure logic looks for an assessment, not a report, to pull the EGA.

      The specific field from which the EGA is pulled would need to be mapped for data submission We recommend you consult with your technical teams, Quality department, EHR vendor and clinical partners to ensure accurate and consistent field mapping for reporting. If mapping is conducted, you should maintain documentation in case of a CMS audit.

      For reporting year 2024, the EGA assessment time must be at the time of delivery or 24 hours prior. For reporting year 2025, the window will be expanded to additionally include EGA assessments after, yet on the same day as delivery.
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      Thank you for inquiring about CMS334/PC-02 Cesarean Birth. The logic looks for the last Estimated Gestational Age (EGA) assessed in a discrete (codified) field. If the nurse completed the patient care assessment form (or flowsheet) by selecting '39 weeks' in a discrete field, and that assessment shows a date and time of 2/28/24 at 08:02 (equal to the delivery date/time) even though the nurse entered the information into the system at 08:15, the last EGA assessed is 39 weeks. The measure logic looks for an assessment, not a report, to pull the EGA. The specific field from which the EGA is pulled would need to be mapped for data submission We recommend you consult with your technical teams, Quality department, EHR vendor and clinical partners to ensure accurate and consistent field mapping for reporting. If mapping is conducted, you should maintain documentation in case of a CMS audit. For reporting year 2024, the EGA assessment time must be at the time of delivery or 24 hours prior. For reporting year 2025, the window will be expanded to additionally include EGA assessments after, yet on the same day as delivery.
    • CMS0334v5

      Does it matter where we are pulling our EGA from in the electronic record? We have multiple places that document the EGA. For example, the patient care assessment under the delivery summary nurse documents at 2/28/24 at 08:15 the delivery date and time (2/28/24 at 08:02 with the estimated or known GA at 39 weeks.) The H&P is always documented after the delivery time with the EGA documented. We also have it documented in the Labor and Delivery summary documented under the Reports.
      Second question is does the EGA have to be documented prior to delivery?

            JLeflore Joelencia Leflore
            thert Tammy Hert
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