Thank you for your inquiry regarding CMS986v4: Global Malnutrition Composite Score. You are correct that instances where the reporter has a patient with more than one eligible hospitalization and a Malnutrition Risk Screening result of “not at risk” for at least one of those hospitalizations, a result of “at risk” during the same measurement period will not be counted. Please continue to follow current measure logic, as specified. The measure development team is actively working on addressing this. We have tested the logic for Reporting Period PY 2026, and this is not an issue observed. We will work with CMS to provide updates, as they are available.

We previously opened a ticket CQM-7728 and the ticket was closed prior to us being able to provide additional feedback. We believe the define criteria is resulting in "not at risk" screen results from other encounters being considered. If a "not at risk" is present even from another encounter, this statement is "false" and does not include the "Contains Encounter". See define statement in description: