Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). We understand the intent of the inquiry is to recommend using a present on admission indicator for STEMI and exclusion diagnoses captured in the measure. The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. A patient with a STEMI diagnosis may be captured in the measure in two ways, as indicated by the measure logic definition below found in the measure’s HTML file posted on the eCQI Resource Center [ https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996-v6.3.000-QDM.html ]: ED Encounter with STEMI Diagnosis "ED Encounter During MP" EDEncounterinMP     where (exists (["Diagnosis": "STEMI"] DxSTEMI       where DxSTEMI.prevalencePeriod starts during EDEncounterinMP.relevantPeriod))     or (exists( EDEncounterinMP.diagnoses EncounterDiagnosis       where EncounterDiagnosis.code in "STEMI" ))   First, a STEMI diagnosis can be pulled directly from the ED encounter if a STEMI diagnosis was coded during the encounter. Second, the patient can have a diagnosis pulled from a claim, problem list, or other source in the EHR as long as the prevalencePeriod of the STEMI diagnosis started during the ED encounter relevantPeriod. PrevalencePeriod is an attribute of the “Diagnosis” datatype and signifies the onset dateTime to abatement dateTime of the STEMI diagnosis. RelevantPeriod is an attribute of the “Encounter, Performed”: “Emergency Department Evaluation and Management Visit” datatype and signifies the startTime that the encounter began (admission time) to the stopTime that the encounter ended (discharge time). To differentiate between active and historic diagnoses in the problem list, it’s important for both the onset and abatement times to be populated in the EHR and mapped to the appropriate QDM data elements to avoid misattribution. We emphasize that for a patient to be captured in the measure denominator, they must be 18 years or older and have a STEMI diagnosis during the ED encounter that ends during the measurement period. Therefore, it is not the measure’s intent to capture STEMIs that occurred outside of the patient’s ED encounter. Additionally, many of the measure’s exclusion criteria exclude patients with certain diagnoses that may have started before the ED encounter began. One example of this is the ‘Active Exclusion Diagnosis at the Start of the ED Encounter’ exclusion criteria, which excludes ED encounters with bleeding or bleeding diathesis (excluding menses), known malignant intracranial neoplasm, known structural cerebral vascular lesion, advanced dementia, pregnancy, and diagnosis of allergy to thrombolytics if these diagnoses start before the start of the ED encounter and do not end before the ED encounter. The measure’s ‘Active Exclusion Diagnosis at the Start of the ED Encounter’ definition found in the HTML file [ https://ecqi.healthit.gov/sites/default/files/ecqm/measures/CMS996-v6.3.000-QDM.html ] shows that the diagnosis prevalencePeriod (or time from diagnosis onset to abatement) “overlaps before” the ED encounter relevantPeriod (or the time the encounter began to the time the encounter ended). Meaning, that diagnoses captured by this exclusion can start before or during the ED encounter for the encounter to be excluded from the measure denominator. Although the presentOnAdmissionIndicator attribute is not used for this exclusion, the “overlaps before” measure logic should exclude conditions that were present on admission as long as the “Encounter, Performed”: “Emergency Department Evaluation and Management Visit” relevantPeriod is accurately coded. We highlight that the QDM does not prescribe a presentOnAdmissionIndicator attribute for the “Diagnosis” datatype. However, the measure developer team may consider using a presentOnAdmissionIndicator attribute for the “Encounter, Performed” datatype in a future Annual Update.

It is not standard practice for HIM to capture date and time of a diagnosis, since diagnosis unlike a birth or procedure are not timed. Coding guidelines consider any diagnosis that is linked to the documented plan of care on admission to be present on admission regardless of confirmation post admission. Can the POA YES status be used as an indicator to identify diagnoses for sample and exclusion purposes. Currently, the measure logic is requiring a date and time for diagnoses to be captured and causing the measure to include cases with STEMI diagnosis that should be excluded from measure population. Additionally, it includes cases with exclusions based on diagnoses. The impact is a mischaracterization of our reported scores.