CMS996v6 Encoutner Inpatient with Hospice Diagnosis logic

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    • Type: Hosp Outpt eCQMs - Hospital Outpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). It is the measure’s intention to exclude documentation of hospice services in the six months within the start of the ED encounter, or active hospice status at the start of the ED encounter.

      1. We created a test case for case #1 outlined in the inquiry, and have determined that this particular case is incorrectly triggering the denominator exclusion, which does not align with the exclusion’s intent because the hospice discharge disposition occurred after the end of the ED encounter relevantPeriod. Thank you for bringing this issue to our attention, CMS and the measure developer will consider updating the logic in a future annual update to ensure that hospice documentation occurring after the ED encounter has ended does not trigger the exclusion.
      2. Additionally, we created a test case for case #2, and can confirm that this example does correctly trigger the hospice exclusion due to the “overlaps day of” logic described in the inquiry.
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      Thank you for your inquiry regarding CMS996: Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED). It is the measure’s intention to exclude documentation of hospice services in the six months within the start of the ED encounter, or active hospice status at the start of the ED encounter. 1. We created a test case for case #1 outlined in the inquiry, and have determined that this particular case is incorrectly triggering the denominator exclusion, which does not align with the exclusion’s intent because the hospice discharge disposition occurred after the end of the ED encounter relevantPeriod. Thank you for bringing this issue to our attention, CMS and the measure developer will consider updating the logic in a future annual update to ensure that hospice documentation occurring after the ED encounter has ended does not trigger the exclusion. 2. Additionally, we created a test case for case #2, and can confirm that this example does correctly trigger the hospice exclusion due to the “overlaps day of” logic described in the inquiry.
    • CMS0996v6
    • We are currently blocked from progressing with measure development for client delivery.

      Hello, 
      We'd like to make sure we understand the logic for inpatient encounters with a hospice discharge in the last 6 months:

      ED Encounter With Hospice Services
        from "ED Encounter With STEMI Diagnosis" EDwSTEMI
        let SixMonthsBeforeToEndOfSTEMI: Interval[start of EDwSTEMI.relevantPeriod - 6 months, end of EDwSTEMI.relevantPeriod]
        where (
          exists ( ["Encounter, Performed": "Encounter Inpatient"] InpatientEncounter
            where ( InpatientEncounter.dischargeDisposition ~ "Discharge to home for hospice care (procedure)"
                  or InpatientEncounter.dischargeDisposition ~ "Discharge to healthcare facility for hospice care (procedure)")
                  and ( Global."HasStart" ( InpatientEncounter.relevantPeriod )
                      and InpatientEncounter.relevantPeriod overlaps day of SixMonthsBeforeToEndOfSTEMI
                  )

      Could you please confirm whether our expectations are correct for the following example scenarios?

      * Example 1

      • STEMI-ED visit: 7/31/2025 10:00 am - 7/31/2025 5:00 pm
      • Inpatient encounter w/hospice discharge disposition 7/31/2025 6:30 pm - 8/2/2025 10:00 am 

      Should the patient qualify for denominator exclusion? I would argue Yes, because the inpatient encounter happened partially during the 6-month interval leading up to or overlapping with the ED STEMI visit. 

      * Example 2

      • Inpatient encounter w/hospice discharge disposition 1/29/2025 8:00 am - 1/31/2025 8:00 am.
      • STEMI-ED visit: 7/31/2025 10:00 am - 7/31/2025 5:00 pm

      We believe the SixMonthsBeforeToEndOfSTEMI interval would be 1/31/2025 10:00 am to 7/31/2025 5:00 pm. With that, should we assume, the patient would not qualify for denominator exclusion due to the timing? We think the patient should qualify for exclusion because the logic mentions "InpatientEncounter.relevantPeriod overlaps day of SixMonthsBeforeToEndOfSTEMI" and time is NOT considered due to the "day of"?
      Please let us know what the expectation is.

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Talisa Williams
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              Created:
              Updated:
              Resolved:
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