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Type:
Hosp Inpt eCQMs - Hospital Inpatient eCQMs
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Resolution: Answered
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Priority:
Moderate
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Component/s: None
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None
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CMS0986v4
Hello - when determining the Eligible Occurrences/Denominators for Observation 6 the Note from MetaData/Guidance Section does not align with the Total Malnutrition Composite Score Eligible Occurrences(Encounter "Encounter, Performed") ** function.
The Total Malnutrition Composite Score Eligible Occurrences(Encounter "Encounter, Performed") function states:
- If the encounter has a Malnutrition Not At Risk Result and does NOT have a Hospital Dietitian Referral the Eligible Occurrence/denom is 1.
- The Eligible Occurrence/denom is a 2 if:
The encounter has a Malnutrition At Risk Result OR a Hospital Dietitian Referral AND a Nutrition Assessment Status Not or Mildly Malnourished OR the Nutrition Assessment Status was not identified/completed.
- Anything else will have an Eligible Occurrence/denom of 4.
However, in the MetaData/Guidance Section it states if a Malnutrition NOT At Risk Result was identified AND Hospital Dietitian Referral was ordered the Eligible Occurrence/denom will be a 2. But if a Nutrition assessment is complete with a result of Moderately Malnourished OR Severely Malnourished shouldn't the eligible occurrence be a 4?
We think the function and the Metadata/Guidance section are confusing and not clear. Maybe the function needs updated in the future to include the high lighted scenario below and for that scenario the Nutrition Assessment was not performed or the nutrition assessment was performed with a result of Not or Mildly Malnourished.
We plan to follow the function (attached) in the CQL logic counting Eligible Occurrence/Denom as 4. Please let us know what the expectation is and any plans to either update the Guidance section or the CQL logic in the future.