Clarification of Hospital Harm - Pressure Injury (HH-PI) CMS826v2

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
    • Lori Griffiths
    • 2163182982
    • Cleveland Clinic
    • Hide
      Thank you for your inquiry regarding CMS826v3, Hospital Harm - Pressure Injury. Please see a response below to each scenario presented:

      Scenario 1:
      This measure excludes the following inpatient hospitalizations from the measure's denominator:
      - Inpatient hospitalizations for patients with a deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury diagnosis present on admission as indicated by a present on admission (POA) indicator of Y or W.
      - Inpatient hospitalizations for patients with a DTPI found on exam 72 hours or less after the start of the encounter.
      - Inpatient hospitalizations for patients with a stage 2, 3, 4, or unstageable pressure injury found on exam 24 hours or less after the start of the encounter.

      Because this eCQM assesses patient data from the patient's entire hospitalization period, if a POA indicator of "Y" or "W" is assigned for a DTPI or a stage 2, 3, 4, or unstageable pressure injury, the inpatient hospitalization for that patient will meet the denominator exclusion criteria, regardless of when the POA indicator status was updated by the hospital. Therefore, if there is documentation of the stage 2 pressure injury with a POA indicator of "Y" or "W" 48 hours after the patient's inpatient admission (or anytime during the hospitalization), then this inpatient hospitalization would be excluded from the measure's denominator and therefore excluded from measure calculation. However, if the documentation of the stage 2 pressure injury comes from skin exam findings 48 hours after the patient's inpatient admission, then the patient would not meet the denominator exclusion criteria and may meet the numerator criteria of this measure.
       
      Scenario 2:
      For this measure, the inpatient hospitalization period includes time in the emergency department (ED) and/or observation status when the transition between discharge from these encounters and the start of the inpatient encounter is one hour or less. If there is more than one hour between the ED encounter end and the start of the inpatient encounter, then the inpatient hospitalization period assessed by this measure would begin at the start of the inpatient encounter. But if there is one hour or less between the ED encounter end and the start of the inpatient encounter, then the inpatient hospitalization period assessed by this measure would begin at the start of the ED encounter. Because the scenario you provided does not specify the ED encounter end time, we are not able to make a determination as to when the inpatient hospitalization period starts for this scenario. We recommend that each hospital team works internally to confirm the criteria that are used to determine the start of a patient’s inpatient status, as this may vary by different hospital or payer requirements
       
      Scenario 3:
      Once a patient's stage 2, 3, 4, unstageable, or deep tissue pressure injury is assigned a POA indicator of "Y", then the inpatient hospitalization for this patient is excluded from the measure's denominator and is therefore excluded from the measure calculation. Because this inpatient hospitalization would be excluded from the measure's calculation, the progression of this pressure injury and/or any new pressure injuries that the patient develops later in the hospitalization (either at the original pressure injury site or another site) would not qualify the patient's hospitalization for the measure's numerator. However, if the POA indicator for the original stage 2 pressure injury is changed from "Y" to "N", then this inpatient hospitalization may meet the numerator criteria. For this measure, the provider type that may document results for data elements related to pressure injury diagnoses depends on scope of practice guidelines and on each hospital’s clinical workflow. If you have questions about the specific data source(s) used for each data element, we recommend that you reach out to the hospital’s electronic health record (EHR) vendor for clarification.
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      Thank you for your inquiry regarding CMS826v3, Hospital Harm - Pressure Injury. Please see a response below to each scenario presented: Scenario 1: This measure excludes the following inpatient hospitalizations from the measure's denominator: - Inpatient hospitalizations for patients with a deep tissue pressure injury (DTPI) or stage 2, 3, 4, or unstageable pressure injury diagnosis present on admission as indicated by a present on admission (POA) indicator of Y or W. - Inpatient hospitalizations for patients with a DTPI found on exam 72 hours or less after the start of the encounter. - Inpatient hospitalizations for patients with a stage 2, 3, 4, or unstageable pressure injury found on exam 24 hours or less after the start of the encounter. Because this eCQM assesses patient data from the patient's entire hospitalization period, if a POA indicator of "Y" or "W" is assigned for a DTPI or a stage 2, 3, 4, or unstageable pressure injury, the inpatient hospitalization for that patient will meet the denominator exclusion criteria, regardless of when the POA indicator status was updated by the hospital. Therefore, if there is documentation of the stage 2 pressure injury with a POA indicator of "Y" or "W" 48 hours after the patient's inpatient admission (or anytime during the hospitalization), then this inpatient hospitalization would be excluded from the measure's denominator and therefore excluded from measure calculation. However, if the documentation of the stage 2 pressure injury comes from skin exam findings 48 hours after the patient's inpatient admission, then the patient would not meet the denominator exclusion criteria and may meet the numerator criteria of this measure.   Scenario 2: For this measure, the inpatient hospitalization period includes time in the emergency department (ED) and/or observation status when the transition between discharge from these encounters and the start of the inpatient encounter is one hour or less. If there is more than one hour between the ED encounter end and the start of the inpatient encounter, then the inpatient hospitalization period assessed by this measure would begin at the start of the inpatient encounter. But if there is one hour or less between the ED encounter end and the start of the inpatient encounter, then the inpatient hospitalization period assessed by this measure would begin at the start of the ED encounter. Because the scenario you provided does not specify the ED encounter end time, we are not able to make a determination as to when the inpatient hospitalization period starts for this scenario. We recommend that each hospital team works internally to confirm the criteria that are used to determine the start of a patient’s inpatient status, as this may vary by different hospital or payer requirements   Scenario 3: Once a patient's stage 2, 3, 4, unstageable, or deep tissue pressure injury is assigned a POA indicator of "Y", then the inpatient hospitalization for this patient is excluded from the measure's denominator and is therefore excluded from the measure calculation. Because this inpatient hospitalization would be excluded from the measure's calculation, the progression of this pressure injury and/or any new pressure injuries that the patient develops later in the hospitalization (either at the original pressure injury site or another site) would not qualify the patient's hospitalization for the measure's numerator. However, if the POA indicator for the original stage 2 pressure injury is changed from "Y" to "N", then this inpatient hospitalization may meet the numerator criteria. For this measure, the provider type that may document results for data elements related to pressure injury diagnoses depends on scope of practice guidelines and on each hospital’s clinical workflow. If you have questions about the specific data source(s) used for each data element, we recommend that you reach out to the hospital’s electronic health record (EHR) vendor for clarification.
    • CMS0826v3
    • CMS0826v2
    • We require additional guidance on Hospital Harm - Pressure Injury (HH-PI) CMS826v2. - eCQM Measure Outcome

      Specifically:

      Scenario 1: • At admission a nurse (not an Advance Practice RN) documents a wound but does not identify it as a pressure ulcer. •48 hours later an APRN or Physician documents a stage 2 pressure injury present on admission and adds it to the problem list. Does documentation from a bedside nurse (not an APRN or Physician) impact this measure's outcome? Which data will be pulled into the final eCQM report?

      Scenario 2: • Patient arrives at the emergency room 12/01/2025 at 13:00. • Admit to inpatient order 12/01/2025 at 14:00. • Patient arrives at the inpatient department 12/01/2025 at 15:00. Which of these times would start the 24-hour clock for PI and the 72-hour for DPTI?

      Scenario 3: • A wound care APRN documents a stage 2 pressure injury 'present on admission' and adds it to the problem list, 12/01/2025 at 12:00. • A Physician documents stage 2 pressure injury 'not present on admission' and adds it to the problem list, 12/01/2025 at 15:00. Would this patient be included or excluded from the numerator? Overall: Are covered entities allowed to determine a documentation hierarchy for the HH:PI eCQM? For example, prioritizing wound care APRNs' documentation over Physicians' documentation, due to their high level of expertise.

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Lori Griffiths
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