Thank you for your question regarding CMS826v2, Hospital Harm - Pressure Injury. Regarding your first question: The inpatient hospitalization period assessed by this measure includes time in the emergency department (ED) and/or observation when the transition between discharge from these encounters and admission to the inpatient encounter is one hour or less. For example, if a patient is discharged from the ED at 9:45AM and admitted to the inpatient encounter at 10AM on the same day, then the inpatient hospitalization period assessed for that patient would begin at the start of the patient’s ED encounter. The measure considers a deep tissue pressure injury (DTPI) to be present on admission if the DTPI diagnosis has a Present on Admission (POA) indicator of “Y” or “W” or if the DTPI was found on skin exam 72 hours or less after the start of the inpatient hospitalization period. The measure considers a stage 2, 3, 4, or unstageable pressure injury to be present on admission if the pressure injury diagnosis has a POA indicator of “Y” or “W” or if the pressure injury was found on skin exam 24 hours or less after the start of the inpatient hospitalization period. Regarding your second question: This eCQM pulls from patient data entered in a hospital's electronic health record (EHR) system, including diagnosis codes, test and assessment results, and POA indicators. We recommend that each hospital work with its EHR vendor to determine the specific data sources that are being used for eCQM reporting.

Affecting elapsed time durations, e.g. 24 hrs per PI and 72 hrs DTPI, based on start date/times to reporting date/times. Also, affecting the capturing of diagnosis, per local interpretations are including nurse documentation references in flowsheets, etc., surrounding nurse documentation care diagnosis versus only established medical diagnosis by physicians/APPs.