Nursing Home Exclusion Clarification

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    • Type: EC eCQMs - Eligible Clinicians
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: Guidance
    • None
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      Thank you for your inquiry about the advanced illness and frailty exclusion criteria for CMS122v13 (performance period 2025). To clarify, the exclusion criteria "Is Age 66 or Older Living Long Term in a Nursing Home" requires patients 66 or older at the end of the measurement period where the last housing status assessment performed (LOINC code 71802-3) has a result of "lives in a nursing home (finding)" (SNOMED code 160734000). The intent of this exclusion is to identify individuals who are likely to be living in a nursing home any time on or before the end of the measurement period and receiving institutionalized long-term care services. The measure does not prescribe how this information should be documented in structured fields of EHRs. We recommend you consult with your EHR vendor and clinical partners. Clinically equivalent services can be mapped to the codes; if mapping is done, you should maintain documentation in case of a CMS audit.

      If you have questions about reading the measure specification or understanding data requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs
      Show
      Thank you for your inquiry about the advanced illness and frailty exclusion criteria for CMS122v13 (performance period 2025). To clarify, the exclusion criteria "Is Age 66 or Older Living Long Term in a Nursing Home" requires patients 66 or older at the end of the measurement period where the last housing status assessment performed (LOINC code 71802-3) has a result of "lives in a nursing home (finding)" (SNOMED code 160734000). The intent of this exclusion is to identify individuals who are likely to be living in a nursing home any time on or before the end of the measurement period and receiving institutionalized long-term care services. The measure does not prescribe how this information should be documented in structured fields of EHRs. We recommend you consult with your EHR vendor and clinical partners. Clinically equivalent services can be mapped to the codes; if mapping is done, you should maintain documentation in case of a CMS audit. If you have questions about reading the measure specification or understanding data requirements, you may refer to the "Guide for Reading eCQMs" for additional guidance. If you have questions regarding implementing the measure, you may refer to the "Implementation Checklist for eCQM Annual Update" for additional guidance. These resources can be found in the eCQI Resource Center: https://ecqi.healthit.gov/ep-ec?qt-tabs_ep=ecqm-resources&global_measure_group=eCQMs
    • CMS0122v13

      Hello,

      My organization would like clarification on the nursing home-based exclusion: "Exclude patients 66 and older by the end of the measurement period who are living long term in a nursing home any time on or before the end of the measurement period," and whether it is possible to use qualification methods other than specified in the CQL logic.

      I understand that patients are qualified as being in a nursing home using Housing Assessment (LOINC 71802-3) data, however, the EHR that we use has not historically supported submission of that assessment. This EHR has alternate methods of qualifying a patient as living long-term in a nursing home, including "SNF" tags and location data. Some have raised the idea that a patient with an internal "SNF" tag that is active at any point during the measurement period could qualify for a nursing home-based exclusion.

      The question is then: is this "SNF" tag-based concept at all compatible with eCQM reporting, or do these patients need to strictly have Housing Assessments with "Lives in a nursing home" findings to qualify for the nursing home-based exclusion? 

      I appreciate your time.

            Assignee:
            AIR EC eCQM Team
            Reporter:
            Elias Cichetti
            Elias Cichetti
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