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  2. CQM-7343

STEMI-ED Major Surgical Procedure value set has contradictory exclusion logic

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    • Icon: OQR eCQMs - Outpatient Quality Reporting OQR eCQMs - Outpatient Quality Reporting
    • Resolution: Answered
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    • Melissa Fehnel
    • 484-862-4255
    • Lehigh Valley Health Network
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      Thank for your inquiry regarding CMS996v4: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) measure. Our understanding of your inquiry is that stent placement is mapped to SNOMED code 449389000 (Placement of stent in cardiac conduit (procedure)), which results in excluding cases that should have met the numerator criteria. The measure developer will investigate this issue and consider refinements to the value set or exclusion criterion in question for an upcoming Annual Update. Please note that the earliest that any changes may be considered for implementation is report period 2026.
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      Thank for your inquiry regarding CMS996v4: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED) measure. Our understanding of your inquiry is that stent placement is mapped to SNOMED code 449389000 (Placement of stent in cardiac conduit (procedure)), which results in excluding cases that should have met the numerator criteria. The measure developer will investigate this issue and consider refinements to the value set or exclusion criterion in question for an upcoming Annual Update. Please note that the earliest that any changes may be considered for implementation is report period 2026.
    • CMS0996v4
    • Most of our patients who received PCI within the appropriate timeframe are hitting Denominator Exclusion rather than Numerator due to a SNOMED code for placement of stent in a cardia conduit being in the Major Surgical Procedure value set

      SNOMED#449389000 - Placement of stent in cardiac conduit (procedure) is contained in value set 2.16.840.1.113883.3.3157.4056 for Major Surgical Procedure. 

      Appropriate care would require "Procedure, Performed: Percutaneous Coronary Intervention" within 90 minutes of arrival for non-transfer patients. As part of the appropriate PCI workflow, we have automated data mapping by our vendor as part of the coronary angioplasty workflow.  When stent placement is selected, it is mapped to SNOMED#449389000.

      Because of this automated data mapping, patients who have appropriate care of PCI within 90 minutes of arrival are being evaluated in the Denominator Exclusion because this SNOMED code is included in the Major Surgical Procedure value set. 

      Denominator Exclusion satisfied by stent placement intra-procedure documentation during PCI 

      "Major Surgical Procedure 21 Days or Less Before End of ED Encounter"

      Can anything be done this year to resolve this issue? 

      We would recommend a closer evaluation of the Major Surgical Procedure value set to remove terminologies that could be incidentally documented as part of the PCI workflow. Alternately, the criterion could be moved to the Denominator Exception to allow for appropriate numerator workflows to be captured first.

            aweber Mathematica EH eCQM Team
            V0290 Melissa Fehnel
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