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CMS986v4-Total Malnutrition Composite Score Eligible Occurrences

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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 thoughtful review of CMS986 Global Malnutrition Composite Score. In the current measure logic, to obtain a score of 1 for MO2 (Nutrition Assessment), an encounter must meet the condition ("Encounter with Nutrition Assessment and Identified Status" contains Encounter) in addition to satisfying MO1 (Nutrition Risk Screening/Hospital Dietitian Referral) and the remaining above-mentioned conditions specified in the MO2 function. In other words, to ensure the result for MO2 is 1, a Nutrition Assessment must be documented, regardless of the result of the assessment (Not/Mild/Well Malnourished, or Moderately Malnourished, or Severely Malnourished).

      To achieve a 2 for ("Total Malnutrition Composite Score Eligible Occurrences Encounter "Encounter, Performed") function, the measure logic stops if there is no Nutrition Assessment documented, resulting in an Eligible Occurrence of 2. For other scenarios where the Eligible Occurrence equals 2, please refer to CQM-7141 (https://oncprojectracking.healthit.gov/support/browse/CQM-7141) for an explanation of those logic pathways.

      Additionally, the measure flow diagram (https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS986v4-eCQMFlow.pdf) on the eCQI website can help clarify the calculation based on documentation of the measure observations. Other resources, such as a ‘possible combination table’ (https://www.cdrnet.org/vault/2459/web/AU2024%20Measure%20Calculations%20Table.pdf) can be found at www.cdrnet.org/GMCS, under Implementation Resources.

      The MD team continues to work on simplifying the measure logic for the upcoming calendar year, and we appreciate your review and feedback.
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      Thank you for your thoughtful review of CMS986 Global Malnutrition Composite Score. In the current measure logic, to obtain a score of 1 for MO2 (Nutrition Assessment), an encounter must meet the condition ("Encounter with Nutrition Assessment and Identified Status" contains Encounter) in addition to satisfying MO1 (Nutrition Risk Screening/Hospital Dietitian Referral) and the remaining above-mentioned conditions specified in the MO2 function. In other words, to ensure the result for MO2 is 1, a Nutrition Assessment must be documented, regardless of the result of the assessment (Not/Mild/Well Malnourished, or Moderately Malnourished, or Severely Malnourished). To achieve a 2 for ("Total Malnutrition Composite Score Eligible Occurrences Encounter "Encounter, Performed") function, the measure logic stops if there is no Nutrition Assessment documented, resulting in an Eligible Occurrence of 2. For other scenarios where the Eligible Occurrence equals 2, please refer to CQM-7141 ( https://oncprojectracking.healthit.gov/support/browse/CQM-7141 ) for an explanation of those logic pathways. Additionally, the measure flow diagram ( https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS986v4-eCQMFlow.pdf ) on the eCQI website can help clarify the calculation based on documentation of the measure observations. Other resources, such as a ‘possible combination table’ ( https://www.cdrnet.org/vault/2459/web/AU2024%20Measure%20Calculations%20Table.pdf ) can be found at www.cdrnet.org/GMCS, under Implementation Resources. The MD team continues to work on simplifying the measure logic for the upcoming calendar year, and we appreciate your review and feedback.
    • CMS0986v4

      After developing CMS 986 GMCS:Global Malnutrition Composite Score and combing through JIRA's to try to understand how to get a score of 1 for Population 2, Measure Observation by not having "Encounter with Nutrition Assessment and Identified Status", we had some recommendations for the specifications to make it more clear for how to achieve the 2 in "Total Malnutrition Composite Score Eligible Occurrences(Encounter "Encounter, Performed")" function.

      Instead we believe Population 2, Measure Observation should read as follows:

      Sum (
       if ( "Encounter with Malnutrition Not at Risk Result and without Hospital Dietitian Referral" ) contains Encounter then 0
       else if ( "Encounter with Nutrition Assessment and Identified Status" contains Encounter
         and ( ( "Encounter with Nutrition Assessment Status Not or Mildly Malnourished" contains Encounter
               or "Encounter with Nutrition Assessment Status Finding of Moderately Malnourished" contains Encounter
               or "Encounter with Nutrition Assessment Status Finding of Severely Malnourished" contains Encounter
           )
             and ( ( "Encounter with Malnutrition Risk Screening and Identified Result or with Hospital Dietitian Referral" contains Encounter
                   and "Encounter with Malnutrition Screening At Risk Result" contains Encounter
               )
                 or ( "Encounter with Hospital Dietitian Referral" ) contains Encounter
             )
         )
      )
      or else if NOT ("Encounter with Nutrition Assessment and Identified Status" contains Encounter)
        then 1
       else 0
      )

            aweber Mathematica EH eCQM Team
            joe.long@oracle.com Joseph Long
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