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  1. eCQM Issue Tracker
  2. CQM-7725

HH-02 Denominator Exclusion

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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 regarding CMS871v4, Hospital Harm – Severe Hyperglycemia. Regarding the timing of the denominator exclusions criteria, an inpatient hospitalization period includes time in the emergency department (ED) and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. Therefore, if the transition time between the ED encounter and the inpatient admission is an hour or less, then the ED start date and time would be used to calculate the seven-hour period that is evaluated in the denominator exclusions criteria (one hour prior to the start of the ED encounter to six hours after the start of the ED encounter).
      Regarding the glucose results, the measure logic looks specifically for results that are >=1,000 mg/dL. A patient with a glucose result of “>600 mg/dL” but less than 1000 mg/dL within one hour prior to the start of the encounter to six hours after the start of the encounter would not meet the denominator exclusions criteria. However, we will consider your feedback about glucose test workflows in future updates to the measure.
      Show
      Thank you for your question regarding CMS871v4, Hospital Harm – Severe Hyperglycemia. Regarding the timing of the denominator exclusions criteria, an inpatient hospitalization period includes time in the emergency department (ED) and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other. Therefore, if the transition time between the ED encounter and the inpatient admission is an hour or less, then the ED start date and time would be used to calculate the seven-hour period that is evaluated in the denominator exclusions criteria (one hour prior to the start of the ED encounter to six hours after the start of the ED encounter). Regarding the glucose results, the measure logic looks specifically for results that are >=1,000 mg/dL. A patient with a glucose result of “>600 mg/dL” but less than 1000 mg/dL within one hour prior to the start of the encounter to six hours after the start of the encounter would not meet the denominator exclusions criteria. However, we will consider your feedback about glucose test workflows in future updates to the measure.
    • CMS0871v4
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      Denominator Exclusion: Inpatient hospitalizations for patients with a glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter.

      What date/time is used for the 1-hour and 6-hour windows? ED Start Date/Time or Inpatient Start Date/Time?
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      Denominator Exclusion: Inpatient hospitalizations for patients with a glucose result of >=1000 mg/dL anytime between 1 hour prior to the start of the encounter to 6 hours after the start of the encounter. What date/time is used for the 1-hour and 6-hour windows? ED Start Date/Time or Inpatient Start Date/Time?

      Would CMS accept ">600 mg/dL" as the Glucose Lab Test?  It's not the actual result.  Our current workflow is that the nurse does a fingerstick blood glucose test at the bedside and if it comes back >600, lab will come to do a blood draw because the glucose could be 601 or 1001, and the actual value will then be documented in the EMR.  Our vendor can pull in the ">600 mg/dL" only in this case.

            aweber Mathematica EH eCQM Team
            icheong Isabel Cheong
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