CMS108v13- Encounter with Intervention Comfort Measures from Day of Start of Hospitalization To Day After Admission

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
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      Thank you for your question regarding Venous Thromboembolism Prophylaxis (CMS108v13).

      The comfort measures were performed/ordered on 2025-06-25T14:00:00.000+00:00, which falls on the same calendar day as the start of the second inpatient encounter (2025-06-25T14:58:00.000+00:00). Although the comfort measure time precedes the inpatient encounter start time, the measure evaluates this criterion using day-level (calendar date) precision, not exact DateTime comparison.

      Per the denominator exclusion definition “Intervention Comfort Measures From Day of Start of Hospitalization to Day After Admission”, the timing logic is based on the day of hospitalization/admission, inclusive, rather than the specific encounter start time. Therefore, a comfort measure occurring at any time on the admission date satisfies the exclusion criteria.

      As a result, this patient appropriately qualifies for the denominator exclusion for the second inpatient encounter.
      Show
      Thank you for your question regarding Venous Thromboembolism Prophylaxis (CMS108v13). The comfort measures were performed/ordered on 2025-06-25T14:00:00.000+00:00, which falls on the same calendar day as the start of the second inpatient encounter (2025-06-25T14:58:00.000+00:00). Although the comfort measure time precedes the inpatient encounter start time, the measure evaluates this criterion using day-level (calendar date) precision, not exact DateTime comparison. Per the denominator exclusion definition “Intervention Comfort Measures From Day of Start of Hospitalization to Day After Admission”, the timing logic is based on the day of hospitalization/admission, inclusive, rather than the specific encounter start time. Therefore, a comfort measure occurring at any time on the admission date satisfies the exclusion criteria. As a result, this patient appropriately qualifies for the denominator exclusion for the second inpatient encounter.
    • CMS0108v13

      Hi Team,
      We are getting output mismatch for cms108v13 for denominator exclusion.
      The patient has two qualifying IP encounters.
      As per cypress, the patient should qualify numerator for one of the encounter and should qualify denominator exclusion for another encounter.

      Encounter 1(Emergency to Inpatient)
      Codes:
      SNOMEDCT: 32485007 - Hospital admission (procedure)
      Time Elements:
      Relevant Period Start: 2025-06-22T16:14:00.000Z
      Relevant Period End: 2025-06-25T14:57:00.000Z

      Codes:
      SNOMEDCT: 4525004 - Emergency department patient visit (procedure)
      Time Elements:
      Relevant Period Start: 2025-06-22T13:41:00.000Z
      Relevant Period End: 2025-06-22T16:14:00.000Z
      Author Date/Time: 2025-06-22T13:41:00.000+00:00
      Other Fields:
      Facility: 4525004 (SNOMEDCT) - Emergency department patient visit (procedure)

      Encounter 2(Inpatient)
      Encounter Inpatient
      Codes:
      SNOMEDCT: 32485007 - Hospital admission (procedure)
      Time Elements:
      Relevant Period Start: 2025-06-25T14:58:00.000Z
      Relevant Period End: 2025-06-28T04:04:00.000Z

      As per cypress, patient should qualify for criteria- Encounter with Intervention Comfort Measures from Day of Start of Hospitalization to Day After Admission. However, when we check data comfort measures were performed/ordered on 2025-06-25T14:00:00.000+00:00. If we compare this date with Encounter 1(Emergency to Inpatient) it does not satisfy the validation for VTE.FromDayOfStartOfHospitalizationToDayAfterAdmission(Encounter "Encounter, Performed") as the Relevant Period End is on 2025-06-25T14:57:00.000Z.
      We cannot consider data for comfort measures for Encounter 2 as 2025-06-25T14:00:00.000+00:00(comfort measures start date/authordatetime) is prior to start(2025-06-25T14:58:00.000Z) of Inpatient encounter.

      Also, PFA the reference ticket raised for same scenario for cms108v12: https://oncprojectracking.healthit.gov/support/browse/CYPRESS-2699

      Kindly help us understand why the Patient is expected to qualify for denominator exclusion.

        1. VTE-1 BI & Cypress mismatch_18 (1).xml
          305 kB

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Simran Motwani
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              Created:
              Updated:
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