Uploaded image for project: 'eCQM Issue Tracker'
  1. eCQM Issue Tracker
  2. CQM-7495

Inappropriate measure failures - OP STEMI Measure

XMLWordPrintable

    • Icon: OQR eCQMs - Outpatient Quality Reporting OQR eCQMs - Outpatient Quality Reporting
    • Resolution: Answered
    • Icon: Moderate Moderate
    • None
    • None
    • Andrea L. Koch
    • 5708987669
    • Hide
      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We have summarized our understanding of each part of your inquiry and provided responses below.

      The intent of your first question is to use coding/billing diagnosis of STEMI in the claims data in conjunction with the ED encounter diagnosis to identify patients that do not have a STEMI diagnosis at ED arrival but develop a STEMI during the ED encounter. We would like to clarify that the Quality Data Model (QDM) does not prescribe the source of the diagnosis data in the EHR, and the STEMI diagnoses may be found in the patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. As such, the measure specification identifies STEMI diagnoses from any of these sources, in accordance with the QDM.
      We acknowledge and appreciate your recommendation that the measure should exclude cases in which PCI may not be clinically appropriate.
      Our understanding of your inquiry is that you are seeking clarity on how to correctly implement the measure exclusion for “Insertion or Replacement of Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start”. In the described scenario, the patient receives the intra-aortic balloon after admission, but the EHR is only able to identify these cases while the patient is in ADT (we presume this is admission-discharge-transfer), so there is concern that this case will not be appropriately excluded. The Insertion or Replacement of Mechanical Circulatory Assist Device value set (OID 2.16.840.1.113883.3.3157.4052) currently identifies procedures for intra-aortic balloon pump (IABP) placement using SNOMEDCT and CPT codes. Additional information about the “mechanical circulatory assist device placement” data element can be found on the eCQI Resource Center: https://ecqi.healthit.gov/mcw/2025/ecqm-dataelement/procedureperformedinsertionorreplacementofmechanicalcirculatoryassistdevice.html

      Specific to #1 and #2 above (STEMI onset after ED arrival and no PCI required), the measure developer will consider refinements in a future Annual Update cycle.
      Show
      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We have summarized our understanding of each part of your inquiry and provided responses below. The intent of your first question is to use coding/billing diagnosis of STEMI in the claims data in conjunction with the ED encounter diagnosis to identify patients that do not have a STEMI diagnosis at ED arrival but develop a STEMI during the ED encounter. We would like to clarify that the Quality Data Model (QDM) does not prescribe the source of the diagnosis data in the EHR, and the STEMI diagnoses may be found in the patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. As such, the measure specification identifies STEMI diagnoses from any of these sources, in accordance with the QDM. We acknowledge and appreciate your recommendation that the measure should exclude cases in which PCI may not be clinically appropriate. Our understanding of your inquiry is that you are seeking clarity on how to correctly implement the measure exclusion for “Insertion or Replacement of Mechanical Circulatory Assist Procedure During ED Encounter or Within 24 Hours of ED Encounter Start”. In the described scenario, the patient receives the intra-aortic balloon after admission, but the EHR is only able to identify these cases while the patient is in ADT (we presume this is admission-discharge-transfer), so there is concern that this case will not be appropriately excluded. The Insertion or Replacement of Mechanical Circulatory Assist Device value set (OID 2.16.840.1.113883.3.3157.4052) currently identifies procedures for intra-aortic balloon pump (IABP) placement using SNOMEDCT and CPT codes. Additional information about the “mechanical circulatory assist device placement” data element can be found on the eCQI Resource Center: https://ecqi.healthit.gov/mcw/2025/ecqm-dataelement/procedureperformedinsertionorreplacementofmechanicalcirculatoryassistdevice.html Specific to #1 and #2 above (STEMI onset after ED arrival and no PCI required), the measure developer will consider refinements in a future Annual Update cycle.
    • CMS0996v5
    • CMS0996v4
    • Poor performance yet hospitals are providing evidence-based care

      Would there be any consideration for the STEMI measure to require BOTH a STEMI ED diagnosis and a coding/billing diagnosis of STEMI in order to be in the population? We are seeing cases where the ED diagnosis is NSTEMI but subsequent ECGs show ST elevations, which is causing measure failures.

      We are seeing issues where the initial ECG is negative but subsequent ECGs (sometimes minutes to hours later) show progression to STEMIs. IS there any consideration to allow hospitals to exclude these cases so they are not measure failures? Since timing is a key factor, the subsequent ECGs could be way outside the window to meet the measure.

      2. We have cases where there are clean caths, so no PCI is performed - we are failing these cases on PCI timing because of no PCIs. In these situations, it is totally appropriate for no PCIs. We could also have non-system delays for PCIs within 90 minutes (patient's anatomy) - is there any consideration to exclude these patients from the population to prevent failures? Can CMS consider adding exclusion criterion for a reason why PCI is not performed or delayed?

      Also - According to my EPIC representative, she can only pull balloon pump insertions while the patient is in ADT as an ED patient, these balloon pumps procedures are done in our advanced cath lab. Our patients are usually admitted to Critical care or Cardiology by this time. How can we exclude these patients undergoing balloon pumps under the current specifications of being an ED patient?

            aweber Mathematica EH eCQM Team
            alkoch@geisinger.edu Andrea L. Koch
            Votes:
            0 Vote for this issue
            Watchers:
            5 Start watching this issue

              Created:
              Updated:
              Resolved:
              Solution Posted On: