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  1. eCQM Issue Tracker
  2. CQM-7333

Clarify Major Surgical Procedure timing

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    • Icon: OQR eCQMs - Outpatient Quality Reporting OQR eCQMs - Outpatient Quality Reporting
    • Resolution: Answered
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    • Susan Shedivy
    • Mayo Clinic
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      Thank for your inquiry regarding CMS0996v4: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) measure. The major surgery exclusion is defined using a window of 21 days or less before start of or starts during ED encounter, as described in the measure specifications: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996v4.html. The measure developer will consider refinements to exclusion logic and relevant codes in a future Annual Update.
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      Thank for your inquiry regarding CMS0996v4: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) measure. The major surgery exclusion is defined using a window of 21 days or less before start of or starts during ED encounter, as described in the measure specifications: https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996v4.html . The measure developer will consider refinements to exclusion logic and relevant codes in a future Annual Update.
    • CMS0996v4
    • Cases are Denominator Exclusions instead of Numerators

      The CMS996v4 Specifications for Denominator Exclusions show "Within 21 days before start of or starts during ED Encounter: Major Surgery. The Release Notes Logic "Updated timing of major surgical procedure denominator exclusion to '21 days or less before start of ED Encounter' to align with other definitions. Please clarify the timing of the Major Surgical Procedure.

      For example, SNOMED code 41339005 Coronary angioplasty is in the Major Surgical Procedure value set, but cases are being excluded because the Major Surgical Procedure relevantPeriod in within the "Encounter, Performed": "Emergency Department Visit" relevantPeriod. If the Major Surgical Procedure timing was 21 days or less before START of ED Encounter, this case would be in the Numerator as the Major Surgical Procedure relevantPeriod would be AFTER the ED Encounter relevantPeriod.

      Thank you.

            aweber Mathematica EH eCQM Team
            SMShedivy Susan Shedivy
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