Uploaded image for project: 'eCQM Issue Tracker'
  1. eCQM Issue Tracker
  2. CQM-7355

2025 eHH-02 has new 'Numerator Exclusions' that is identical to 'Denominator Exclusions'

XMLWordPrintable

    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • The Joint Commission
    • Hide
      Thank you for your question on CMS871v4, Hospital Harm – Severe Hyperglycemia. With this measure being a ratio measure, the measure’s Numerator is pulled directly from the measure’s Initial Population. This is different from proportion measures, being a subset from the measure’s Denominator. Therefore, without Numerator Exclusion criteria, the Denominator Exclusions are not applied to patients in the measure’s Numerator, and these patients would not be excluded from Measure Observation 2 (associated with the Numerator). To ensure that the measure calculation appropriately excludes patients who meet the measure’s exclusion criteria, both Denominator Exclusions and Numerator Exclusions are required. Please refer to the CMS Measure Management Systems (MMS) Hub Measure Calculation document (https://mmshub.cms.gov/sites/default/files/Measure-Calculations.pdf) for more information on ratio measures.
      Show
      Thank you for your question on CMS871v4, Hospital Harm – Severe Hyperglycemia. With this measure being a ratio measure, the measure’s Numerator is pulled directly from the measure’s Initial Population. This is different from proportion measures, being a subset from the measure’s Denominator. Therefore, without Numerator Exclusion criteria, the Denominator Exclusions are not applied to patients in the measure’s Numerator, and these patients would not be excluded from Measure Observation 2 (associated with the Numerator). To ensure that the measure calculation appropriately excludes patients who meet the measure’s exclusion criteria, both Denominator Exclusions and Numerator Exclusions are required. Please refer to the CMS Measure Management Systems (MMS) Hub Measure Calculation document ( https://mmshub.cms.gov/sites/default/files/Measure-Calculations.pdf ) for more information on ratio measures.
    • CMS0871v4
    • The new 'Numerator Exclusions' is redundant and creates needless implementer burden.

      'Numerator Exclusion' and 'Denominator Exclusion' both use the same definition. It seems to us that if an EOC is excluded from the Denominator population by this 'Denominator Exclusion' definition, that this same definition used for 'Numerator Exclusion' will not have anything left to exclude.

      Denominator Exclusions
      "Encounter with Early Glucose Greater Than or Equal to 1000 or with Comfort or Hospice Care"

      Numerator Exclusions
      "Encounter with Early Glucose Greater Than or Equal to 1000 or with Comfort or Hospice Care"

      Our concern is for implementer burden and efficiency. For some implementers, this may be the first measure that uses 'Numerator Exclusion'.

      Is there any way this identical 'Numerator Exclusion' and 'Denominator Exclusion' has an affect on the measure results? If not, can the measure be amended to remove the 'Numerator Exclusion'?

            aweber Mathematica EH eCQM Team
            jdawson@jointcommission.org Julia Dawson
            Votes:
            0 Vote for this issue
            Watchers:
            3 Start watching this issue

              Created:
              Updated:
              Resolved:
              Solution Posted On: