Thank you for your question regarding CMS871v3, Hospital Harm – Severe Hyperglycemia. Based on the information provided, it seems that the patient should only meet the Denominator criteria and not the Numerator criteria. If you could please provide responses to the questions listed below, we can further evaluate the issue.   In the QRDA, is this encounter falling into the Numerator? If so, in the QRDA, is day index 3 or day index 4 being counted as a hyperglycemic event day? Can you confirm that neither day index 3 or day index 4 had glucose results? What date and time was the patient discharged? Does the patient have other glucose results and/or eligible days in their hospitalization? Please note that for this measure, hospital days are not defined as midnight-to-midnight. Rather, they are defined as full 24-hour periods that start at the time of admission to the hospital (including emergency department and observation), excluding the last period before inpatient discharge from the hospital if that period is less than 24 hours. In the scenario you described, it seems that October 1 would fall into both day index 3 (September 30, 12:32 – October 1, 12:31) and day index 4 (October 1, 12:32 – October 2, 12:31), depending on the patient’s discharge date and time. Please see the attached table for an illustration of how the measure determines hospital days.

A patient is falling into the numerator for a day with no blood glucose testing following two consecutive days where a blood glucose level was greater than 200 each day. The day immediately preceding the day with no blood glucose test, the patient had a blood glucose of 98. The EPIC QRDA is not capturing this result in the report. It seems as though the patient should be in the denominator rather than the numerator.