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  1. eCQM Issue Tracker
  2. CQM-7445

CMS334v5 and CMS1028v2 "starts during day of" clarification

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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 questions about CMS334v5, Cesarean Birth, and CMS1028v2, Severe Obstetric Complications.

      In scenario #1 only the encounter at Facility 2 where the delivery occurs should qualify for the initial population.

      In scenario #2 where both encounters occur at the same CCN/facility, both encounters would qualify for the initial population incorrectly due to the "day of" logic for the 2024 reporting period. If possible, only Encounter 2 should be reported. As this could be a potential issue, the "day of" logic was removed from subsequent versions of the specifications beginning with the 2025 reporting year.

      In Scenario #3, if the reporting system at Facility A has access to or shares the EMR system at Facility B and the blood transfusion at Facility B occurs on the same day as the delivery encounter, then the blood transfusion at Facility B would qualify the delivery encounter (Encounter 1) for PC-07 numerator. This scenario would be clinically aligned and meet measure intent.
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      Thank you for your questions about CMS334v5, Cesarean Birth, and CMS1028v2, Severe Obstetric Complications. In scenario #1 only the encounter at Facility 2 where the delivery occurs should qualify for the initial population. In scenario #2 where both encounters occur at the same CCN/facility, both encounters would qualify for the initial population incorrectly due to the "day of" logic for the 2024 reporting period. If possible, only Encounter 2 should be reported. As this could be a potential issue, the "day of" logic was removed from subsequent versions of the specifications beginning with the 2025 reporting year. In Scenario #3, if the reporting system at Facility A has access to or shares the EMR system at Facility B and the blood transfusion at Facility B occurs on the same day as the delivery encounter, then the blood transfusion at Facility B would qualify the delivery encounter (Encounter 1) for PC-07 numerator. This scenario would be clinically aligned and meet measure intent.
    • CMS0334v5, CMS1028v2
    • Potentially impacts measure outcomes for our reports.

      Issue # 1
      We need more clarification around the “starts during day of” logic in PC-02 and PC-07 for some of the procedure value sets (Delivery Procedures, Blood Transfusions, etc.). If the “day of” operator ignores times and only considers dates, can you help us determine the patient outcomes for the patient examples below?

      Scenario #1
      Patient visits CCN/Facility A and transfers to a second CCN/facility B on the same day and delivers baby.
      Encounter 1 *starts at CCN/Facility 1
      Start of InpatientEncounter.relevantPeriod = 11/10/2024 7:00 am
      End of InpatientEncounter.relevantPeriod = 11/10/2024 9:00 am

      Encounter 2 - *Patient transfers to CCN/Facility B and delivers baby during this encounter on the same day as encounter 1
      Start of InpatientEncounter.relevantPeriod = 11/10/2024 10:30 am
      Delivery procedure occurred 11/10/2024  **
      End of InpatientEncounter.relevantPeriod = 11/12/2024 2:00 pm

      • Which encounter should qualify for initial population?

      Scenario #2 Patient has two encounters in the same CCN/facility
      Encounter 1:
      Start of InpatientEncounter.relevantPeriod = 11/10/2024 7:00 am
      End of InpatientEncounter.relevantPeriod = 11/10/2024 9:00 am

      Patient returns and delivers baby on the same day of encounter 1
      Encounter 2:
      Start of InpatientEncounter.relevantPeriod = 11/10/2024 2:00 pm
      Delivery procedure occurred 11/10/2024 during this encounter
      End of InpatientEncounter.relevantPeriod = 11/12/2024 4:00 pm

      • Should both encounters qualify for initial population? Or, Should encounter 2 be the only encounter that qualifies for initial population? We tested this in Cypress and both encounters qualified for IPP.

      Issue #2
      For Blood transfusions, Respiratory Support Procedures Related to COVID 19, etc., is the measure intent to capture these value sets on the same day of the encounter and meet the numerator (Blood transfusions) or denominator exclusions (Respiratory Support Procedures Related to COVID 19) whether or not the transfusion/respiratory procedure occurred during the original delivery encounter? Please look at the example provided below.

      Scenario #3
      Patient visits CCN/Facility A, delivers baby, and transfers to a second CCN/facility B on the same day and has a blood transfer.
      Encounter 1 starts at CCN/Facility A
      Start of InpatientEncounter.relevantPeriod = 11/10/2024 7:00 am
      Delivery procedure occurred 11/10/2024 during this encounter
      End of InpatientEncounter.relevantPeriod = 11/10/2024 11:00 am

      Encounter 2 - Patient transfers to CCN/Facility B and has a blood transfusion on the same day as encounter 1
      Start of InpatientEncounter.relevantPeriod = 11/10/2024 11:15 am
      Blood transfusion occurred 11/10/2024 during this encounter
      End of InpatientEncounter.relevantPeriod = 11/12/2024 2:00 pm

      • Should the blood transfusion qualify for encounter 1 for PC-07 numerator? 

            aweber Mathematica EH eCQM Team
            TWILL2014 Talisa Williams
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