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  1. eCQM Issue Tracker
  2. CQM-7582

GMCS Observation End Performance Calculation

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
    • Resolution: Answered
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    • Damaris Rivera
    • 407-449-0839
    • Orlando Health
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      Thank you for your inquiry regarding CMS986v4, the Global Malnutrition Composite Score (GMCS). For the 2025 Reporting Period, in the absence of both a completed Malnutrition Risk Screening and a Hospital Dietitian Referral, measure performance stops, regardless of the completion of additional measure observations. In the scenario described (no Malnutrition Risk Screening, no Hospital Dietitian Referral, completed Nutrition Assessment with result), the performance score would be 0/4 or 0%. This can be seen in the Flow Diagram on page 2. Similarly, in a scenario with no Hospital Dietitian Referral and a Not At Risk result from Malnutrition Risk Screening, the performance score would be 1/1, or 100%; completion of additional measure observations would not count toward performance scores in this scenario, regardless of their completion (next step on page 10).
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      Thank you for your inquiry regarding CMS986v4, the Global Malnutrition Composite Score (GMCS). For the 2025 Reporting Period, in the absence of both a completed Malnutrition Risk Screening and a Hospital Dietitian Referral, measure performance stops, regardless of the completion of additional measure observations. In the scenario described (no Malnutrition Risk Screening, no Hospital Dietitian Referral, completed Nutrition Assessment with result), the performance score would be 0/4 or 0%. This can be seen in the Flow Diagram on page 2. Similarly, in a scenario with no Hospital Dietitian Referral and a Not At Risk result from Malnutrition Risk Screening, the performance score would be 1/1, or 100%; completion of additional measure observations would not count toward performance scores in this scenario, regardless of their completion (next step on page 10).
    • CMS0986v4
    • Creating the logic that follows CMS specifications

      The 2025 eCQM Flow diagram for the GMCS measure states that if there is no referral and no screening that we are to attribute a 0 to the observation and end performance calculation there.

      But what happens if the patient has a nutrition assessment in which we find that they are well nourished?  This would give the patient an occurrence of 2 since this is irrespective of the screening or referral.  I would expect in this scenario for the patient to be 1/2 but according to the CMS flow diagram the patient would be 0/2.

      Please confirm what we should expect for the observation count and the occurrence count for a patient who had no screening, no referral and had an assessment of well nourished.

      And if your conclusion is 1/2 are we interpreting the flow diagram incorrectly or does there need to be a correction to your documentation?

        1. CMS986v4-eCQMFlow.pdf
          207 kB

            aweber Mathematica EH eCQM Team
            drivera Damaris Rivera
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