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  1. eCQM Issue Tracker
  2. CQM-7470

1028v2 PC-07 Blood transfusion

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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 question about CMS1028v2, Severe Obstetric Complications. Due to the known issue (EKI-23) in which 33 of the 39 codes that were added to the blood transfusion value set (2.16.840.1.113762.1.4.1029.213) for the 2024 reporting year are not consistent with the numerator criteria, the codes without an asterisk (*) on the EKI-23 Table 1 (https://oncprojectracking.healthit.gov/support/secure/attachment/83129/EKI-23%20Table%201.pdf) list should not be mapped. If these terms are inadvisably mapped, hospitals should be aware of the potential discrepancy in their reported data when reviewing for process improvement. Retroactive changes to value sets cannot be applied, as CMS annually determines the publication date for eCQM specifications and associated value sets. Reporting accuracy is dependent on implementers using the exact same unique coded identifiers, based on publication date, when assigning codes to clinical conditions. This known issue has been resolved for the 2025 reporting year measure specifications.
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      Thank you for your question about CMS1028v2, Severe Obstetric Complications. Due to the known issue ( EKI-23 ) in which 33 of the 39 codes that were added to the blood transfusion value set (2.16.840.1.113762.1.4.1029.213) for the 2024 reporting year are not consistent with the numerator criteria, the codes without an asterisk (*) on the EKI-23 Table 1 ( https://oncprojectracking.healthit.gov/support/secure/attachment/83129/EKI-23%20Table%201.pdf ) list should not be mapped. If these terms are inadvisably mapped, hospitals should be aware of the potential discrepancy in their reported data when reviewing for process improvement. Retroactive changes to value sets cannot be applied, as CMS annually determines the publication date for eCQM specifications and associated value sets. Reporting accuracy is dependent on implementers using the exact same unique coded identifiers, based on publication date, when assigning codes to clinical conditions. This known issue has been resolved for the 2025 reporting year measure specifications.
    • CMS1028v2

      I am aware of the (EKI-23) known issue with this eCQM in which 33 of the 39 codes added to the value set during the 2023 annual update process are not consistent with the intent of the measure. However, the 1028v2 value sets still include these codes so they are included by our EHR vendor. Per our vendor, CMS would need to make retroactive changes to already released value sets since the EHR vendor cannot alter the mapping. 

      My question is, if we will be including the codes that are not consistent with the intent of the measure, will CMS apply the "updated" logic to exclude those codes (those without the * from the EKI-23 table) since our EHR vendor can't alter the mapping?

      Thank you!

            aweber Mathematica EH eCQM Team
            aconklin Aranzazu Conklin
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