Source for Pressure Injury eCQM POA status

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Rachel McGee
    • 3126942618
    • Northwestern Medicine
    • Hide
      Thank you for your question regarding CMS826v2, Hospital Harm - Pressure Injury. This eCQM pulls from all patient data entered in a hospital's electronic health record (EHR) system, including diagnosis codes, test and assessment results, and present on admission (POA) indicators. As documentation related to pressure injury diagnoses varies based on individual facility practices, this eCQM assesses multiple data sources to identify pressure injury diagnoses. Specifically, to identify encounters with pressure injuries that may qualify for the measure’s Numerator or Denominator Exclusion criteria, the eCQM logic assesses both POA indicators and physical exam results recorded in the EHR.

      In the logic used to express the measure’s Numerator criteria, the “Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours” and “Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours” definitions are used to identify new pressure injuries as documented by physical exam results, while the “Encounter with New Deep Tissue Pressure Injury Not POA by Indicator” and “Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator” definitions are used to identify new pressure injuries as documented by POA indicators. In the logic used to express the measure’s Denominator Exclusion criteria, the “Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours” and “Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours” definitions are used to identify pressure injuries present on admission as documented by physical exam results, while the “Encounter with Deep Tissue Pressure Injury POA by Indicator” and “Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury POA by Indicator” definitions are used to identify pressure injuries present on admission as documented by POA indicators.
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      Thank you for your question regarding CMS826v2, Hospital Harm - Pressure Injury. This eCQM pulls from all patient data entered in a hospital's electronic health record (EHR) system, including diagnosis codes, test and assessment results, and present on admission (POA) indicators. As documentation related to pressure injury diagnoses varies based on individual facility practices, this eCQM assesses multiple data sources to identify pressure injury diagnoses. Specifically, to identify encounters with pressure injuries that may qualify for the measure’s Numerator or Denominator Exclusion criteria, the eCQM logic assesses both POA indicators and physical exam results recorded in the EHR. In the logic used to express the measure’s Numerator criteria, the “Encounter with New Deep Tissue Pressure Injury by Skin Exam after First 72 Hours” and “Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury by Skin Exam after First 24 Hours” definitions are used to identify new pressure injuries as documented by physical exam results, while the “Encounter with New Deep Tissue Pressure Injury Not POA by Indicator” and “Encounter with New Stage 2, 3, 4 or Unstageable Pressure Injury Not POA by Indicator” definitions are used to identify new pressure injuries as documented by POA indicators. In the logic used to express the measure’s Denominator Exclusion criteria, the “Encounter with Deep Tissue Pressure Injury POA by Skin Exam within First 72 Hours” and “Encounter with Stage 2, 3, 4 or Unstageable Pressure Injury POA by Skin Exam within 24 Hours” definitions are used to identify pressure injuries present on admission as documented by physical exam results, while the “Encounter with Deep Tissue Pressure Injury POA by Indicator” and “Encounter with Stage 2, 3, 4, or Unstageable Pressure Injury POA by Indicator” definitions are used to identify pressure injuries present on admission as documented by POA indicators.
    • CMS0826v2
    • Inaccurate performance being captured due to CMS logic only looking at POA status found in billing/claims system

      We understand that EPIC is pulling POA status from coding but we have found several encounters that have no coding listed however POA status is documented in the wound  flowsheet that the wound was POA but current logic does not capture this documentation. 

       

      Desired outcome from Solution field:

      Proposed measure description for POA status: In addition to clinical electronic health record data, this measure uses Present on Admission (POA) indicators (e.g., POA = U) as found in billing/claims system within the measure criteria OR within wound flowsheet documentation

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Rachel McGee
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              Created:
              Updated:
              Resolved:
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