Thank you for your question regarding CMS826v2, Hospital Harm - Pressure Injury. While the measure relies mostly on patient data from the electronic health record (EHR), the measure does use present on admission (POA) indicators as found in billing/claims data to differentiate pressure injuries present at the time of admission from those conditions that develop during the inpatient admission. When assessing a pressure injury diagnosis result from a physical skin exam, the measure’s denominator exclusions and numerator criteria use data from the patient’s EHR to consider whether the skin exam took place before or after the first 24 to 72 hours of the encounter, depending on the type of pressure injury. However, when assessing POA indicators for pressure injury diagnoses, the 24-to-72-hour time span is not considered. The measure’s denominator exclusions identify inpatient hospitalizations for patients (1) with a deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury diagnosis present on admission or (2) with a diagnosis of a COVID-19 infection during the encounter. An encounter will meet the denominator exclusions criteria if it meets at least one of the conditions outlined in either of the below three categories: 1. For the first category, represented by the “Encounter with Deep Tissue Pressure Injury POA” logic definition, two conditions are considered, and either of the two will suffice: An encounter where the patient is 18 or older and has a DTPI diagnosis, and the diagnosis has a present on admission indicator of “present” or “clinically undetermined.” An encounter where the patient is 18 or older and has a DTPI diagnosis found by a skin exam that started 72 hours or less after the start of the encounter. 2. For the second category, represented by the “Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury POA” logic definition, two conditions are considered, and either of the two will suffice: An encounter where the patient is 18 or older and has a stage 2, 3, 4, or unstageable pressure injury diagnosis, and the diagnosis has a present on admission indicator of “present” or “clinically undetermined." An encounter where the patient is 18 or older and has a stage 2, 3, 4, or unstageable pressure injury diagnosis found by a skin exam that started 24 hours or less after the start of the encounter. 3. For the third category, represented by the “Encounter with Diagnosis of COVID19 Infection” definition, only one condition is considered: An encounter where the patient is 18 or older and has a COVID-19 diagnosis during the encounter.   For encounters that do not meet the denominator exclusions criteria, the measure’s numerator identifies inpatient hospitalizations for patients with a new DTPI or stage 2, 3, 4, or unstageable pressure injury. An encounter will meet the numerator criteria if it meets at least one of the conditions outlined in either of the below two categories: 1. For the first category, represented by the “Encounter with New Deep Tissue Pressure Injury” logic definition, two conditions are considered, and either of the two will suffice: An encounter where the patient is 18 or older and has a DTPI injury diagnosis, and the diagnosis has a present on admission (POA) indicator of “not present on admission” or “documentation insufficient to determine." An encounter where the patient is 18 or older and has a DTPI diagnosis found by a skin exam that started after the first 72 hours of the encounter. 2. For the second category, represented by the “Encounter with New Stage 2, 3, 4, or Unstageable Pressure Injury” logic definition, two conditions are considered, and either of the two will suffice: An encounter where the patient is 18 or older and has a stage 2, 3, 4, or unstageable pressure injury diagnosis, and the diagnosis has a POA indicator of “not present on admission” or “documentation insufficient to determine.” An encounter where the patient is 18 or older and has a stage 2, 3, 4, or unstageable pressure injury diagnosis found by a skin exam that started after the first 24 hours of the encounter.   If a qualifying encounter – that does not meet the denominator exclusions criteria – exists where a patient has a pressure injury diagnosis, and the diagnosis has a POA indicator of “not present on admission” or “documentation insufficient to determine”, then the encounter will meet the numerator criteria without consideration of the timing of the pressure injury diagnosis identification. When the measure’s numerator assesses pressure injury diagnoses results from skin exams, the definitions used for the numerator criteria includes logic that assesses only results from skin exams that started after the first 72 hours of the encounter (for DTPIs) or after the first 24 hours of the encounter (for stage 2, 3, 4, or unstageable pressure injuries) based on data from the EHR. Please see the highlighted portions of the logic below for an illustration of this timing logic: Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours "Encounter with Age 18 and Older" EncounterInpatient   let hospitalizationPeriod: Global."HospitalizationWithObservation" ( EncounterInpatient )   with ["Physical Exam, Performed": "Physical findings of Skin"] SkinExam     such that Global."NormalizeInterval" ( SkinExam.relevantDatetime, SkinExam.relevantPeriod ) starts during Interval[start of hospitalizationPeriod + 72 hours, end of hospitalizationPeriod]       and SkinExam.result in "Pressure Injury Deep Tissue"   Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours "Encounter with Age 18 and Older" EncounterInpatient   let hospitalizationPeriod: Global."HospitalizationWithObservation" ( EncounterInpatient )   with ["Physical Exam, Performed": "Physical findings of Skin"] SkinExam     such that Global."NormalizeInterval" ( SkinExam.relevantDatetime, SkinExam.relevantPeriod ) starts during Interval[start of hospitalizationPeriod + 24 hours, end of hospitalizationPeriod]       and SkinExam.result in "Pressure Injury Stage 2, 3, 4 or Unstageable"