HH-FI Measure Observation 1 Clarification for Denominator Exclusion

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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 feedback regarding CMS1017v2, Hospital Harm - Falls with Injury. Measure observation 1 is associated with the Denominator and represents the total number of eligible days across all encounters which match the initial population/denominator criteria. In the specifications and CQL logic, encounters that meet denominator exclusion criteria are removed before Measure Observation 1 is calculated; if denominator exclusions are met, processing ends for that encounter and its inpatient days are not included in Measure Observation 1.

      Specifically, the initial patient population/denominator is captured by the definition of “Encounter with Age 18 and Older and Length of Stay 120 Days or Less.” To meet this definition the logic looks for an inpatient encounter, which includes an encounter ending during the Measurement Period that is less than 120 days AND age criteria of 18 years or older with an encounter ending during the Measurement Period.

      The denominator exclusion is “Encounter with a Fall present on admission.” If the denominator exclusion criteria are met, processing ends. If denominator exclusion criteria are not met, the sum of the duration in days hospitalization with observation becomes measure observation 1.
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      Thank you for your feedback regarding CMS1017v2, Hospital Harm - Falls with Injury. Measure observation 1 is associated with the Denominator and represents the total number of eligible days across all encounters which match the initial population/denominator criteria. In the specifications and CQL logic, encounters that meet denominator exclusion criteria are removed before Measure Observation 1 is calculated; if denominator exclusions are met, processing ends for that encounter and its inpatient days are not included in Measure Observation 1. Specifically, the initial patient population/denominator is captured by the definition of “Encounter with Age 18 and Older and Length of Stay 120 Days or Less.” To meet this definition the logic looks for an inpatient encounter, which includes an encounter ending during the Measurement Period that is less than 120 days AND age criteria of 18 years or older with an encounter ending during the Measurement Period. The denominator exclusion is “Encounter with a Fall present on admission.” If the denominator exclusion criteria are met, processing ends. If denominator exclusion criteria are not met, the sum of the duration in days hospitalization with observation becomes measure observation 1.
    • CMS1017v2

      The CQL specifications define Measure Observation 1 as follows:

      Denominator Observation, associated with the Denominator:
      The total number of eligible days across all encounters that meet the initial population and denominator criteria.

      However, the specifications and CQL logic do not explicitly state that encounters meeting denominator exclusion criteria should be excluded from Measure Observation 1. In contrast, the provided flow chart indicates that Measure Observation 1 counts the number of eligible hospitalization days that meet the denominator criteria and do not meet the denominator exclusion criteria.

      For Measure Observation 1 qualification, should we follow:

      The specifications, which describe Measure Observation 1 as all eligible days across encounters meeting the initial population and denominator criteria; or

      The flow chart, which limits Measure Observation 1 to eligible days that meet the denominator criteria and do not meet denominator exclusions?

      Additionally, if the flow chart definition is the intended logic, can the 2027 specifications be updated to reflect this behavior?

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Talisa Williams
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