CMS 986 Eligible Occurrences for Multiple Nutrition Assessment Results

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for your inquiry regarding CMS986v4, the Global Malnutrition Composite Score (GMCS). For the example scenario, that is correct, the function Total Malnutrition Composite Score Eligible Occurrence would result in a score of 2 for reporting period 2025 as timing during the encounter is not considered.

      For Reporting Period Calendar Year 2026, the logic was updated to prioritize the most recent Nutrition Assessment result. In the proposed scenario, if the Severely Malnourished Nutrition Assessment Result is the most recent one, then the Total Malnutrition Composite Score Eligible Occurrence will be 4. This update was done to align better with the measure intent and address iatrogenic malnutrition.
      Show
      Thank you for your inquiry regarding CMS986v4, the Global Malnutrition Composite Score (GMCS). For the example scenario, that is correct, the function Total Malnutrition Composite Score Eligible Occurrence would result in a score of 2 for reporting period 2025 as timing during the encounter is not considered. For Reporting Period Calendar Year 2026, the logic was updated to prioritize the most recent Nutrition Assessment result. In the proposed scenario, if the Severely Malnourished Nutrition Assessment Result is the most recent one, then the Total Malnutrition Composite Score Eligible Occurrence will be 4. This update was done to align better with the measure intent and address iatrogenic malnutrition.
    • CMS0986v4

      We’d like to confirm that we’re interpreting the CQL logic correctly for the Total Malnutrition Composite Score Eligible Occurrences, particularly when multiple nutrition assessments are documented.

      For example, consider an inpatient encounter with the following:

      • A Malnutrition Risk Screening showing a “Not at Risk” result and a Hospital Dietitian Referral Order
      • Two nutrition assessments with results:
        1. “Not or Mildly Malnourished”
        1. “Severely Malnourished”
      • A malnutrition diagnosis
      • A nutrition care plan

      Based on our understanding, the eligible occurrence for this encounter should be 2 because of the “Not or Mildly Malnourished” nutrition assessment.

      Could you please confirm what the eligible denominator should be in this scenario?

      Thank you!

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            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Talisa Williams
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