Clarification on Qualifying Values for the "Laboratory Test, Performed" Value Set (CMS816, CMS871)

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Tammie Trefz
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      Thank you for your question regarding CMS816v5, Hospital Harm - Severe Hypoglycemia (HH-Hypo) and CMS871v5, Hospital Harm - Severe Hyperglycemia (HH-Hyper). For both the HH-Hypo and HH-Hyper eCQMs, the specimen source for the glucose test is blood, serum, plasma, or interstitial fluid and can be obtained by a laboratory test, a point-of-care (POC) test, or a continuous glucose monitor (CGM). This includes results obtained from a glucometer. Both measures use the ["Laboratory Test, Performed": "Glucose Lab Test Mass Per Volume"](https://ecqi.healthit.gov/mcw/2026/ecqm-dataelement/laboratorytestperformedglucoselabtestmasspervolume.html) QDM data element. For more information on the types of glucose test results and specimen sources that are considered by the measures, users may review the LOINC codes included in the “Glucose Lab Test Mass Per Volume” value set (OID: 2.16.840.1.113762.1.4.1248.34) on the Value Set Authority Center (VSAC)(https://vsac.nlm.nih.gov/).

      Unfortunately, we are not able to provide guidance on how to map data elements within a health system due to variations specific to electronic health records (EHRs) and how health systems implement them. For this situation, we recommend that the health system’s reporting team work internally and with the health system's EHR vendor as needed to determine which data source contains the most up-to-date and/or accurate patient data for reporting and map the data source accordingly.
      Show
      Thank you for your question regarding CMS816v5, Hospital Harm - Severe Hypoglycemia (HH-Hypo) and CMS871v5, Hospital Harm - Severe Hyperglycemia (HH-Hyper). For both the HH-Hypo and HH-Hyper eCQMs, the specimen source for the glucose test is blood, serum, plasma, or interstitial fluid and can be obtained by a laboratory test, a point-of-care (POC) test, or a continuous glucose monitor (CGM). This includes results obtained from a glucometer. Both measures use the ["Laboratory Test, Performed": "Glucose Lab Test Mass Per Volume"]( https://ecqi.healthit.gov/mcw/2026/ecqm-dataelement/laboratorytestperformedglucoselabtestmasspervolume.html ) QDM data element. For more information on the types of glucose test results and specimen sources that are considered by the measures, users may review the LOINC codes included in the “Glucose Lab Test Mass Per Volume” value set (OID: 2.16.840.1.113762.1.4.1248.34) on the Value Set Authority Center (VSAC)( https://vsac.nlm.nih.gov/ ). Unfortunately, we are not able to provide guidance on how to map data elements within a health system due to variations specific to electronic health records (EHRs) and how health systems implement them. For this situation, we recommend that the health system’s reporting team work internally and with the health system's EHR vendor as needed to determine which data source contains the most up-to-date and/or accurate patient data for reporting and map the data source accordingly.
    • CMS0816v5
    • CMS0816v4
    • eCQM reporting accuracy

      We are seeking clarification on whether a specific documentation field in the Electronic Health Record (EHR) qualifies to be mapped to a code in the "Laboratory Test, Performed" value set for the CMS measures CMS816 (Hospital Harm - Severe Hypoglycemia) and CMS871 (Hospital Harm - Severe Hyperglycemia).  

      Scenario Details:

      Context: Within the EHR's Medication Administration Record (MAR), when a nurse is administering insulin, there is a dedicated field where the nurse records the patient's most recent blood glucose result.

      • The Discrete Task Assay Activity Type:  “Patient Care”
      • Field Name: "Blood Glucose, Point of Care"
      • Data Type: Numeric
      • Units of Measure: mg/dl

      Question:

      Given that the documented field "Blood Glucose, Point of Care" contains a numeric result in mg/dl in the official medical record, does this entry qualify to be associated (mapped) as a "Laboratory Test, Performed" for the CMS measures CMS816 and CMS871?

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Tammie Trefz
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              Created:
              Updated:
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