Thank you for your inquiry regarding CMS986v4, the Global Malnutrition Composite Score (GMCS, now known as the Malnutrition Care Score). Observations 2-4 are dependent on the presence of either a Malnutrition Risk Screening result or a Hospital Dietitian Referral, as defined in the measure specifications. Observation 2 applies to encounters with a Malnutrition Risk Screening that has an identified result or encounters with a Hospital Dietitian Referral (“Encounter with Malnutrition Risk Screening and Identified Result or with Hospital Dietitian Referral”). If neither a Malnutrition Risk Screening with a documented result nor a Hospital Dietitian Referral is present, then Observations 2–4 cannot be met. In those cases, the encounter is scored as 0 out of 4 (0%). We understand how this can cause confusion as 0/1 and 0/4 both equal 0%. The occurrence of 4 is retained to keep scoring consistent across encounters, even when required documentation is missing. In those cases, the measure is designed to appropriately score as 0%. In addition, keeping the Eligible Occurrence as a 4 in this instance, aligns with the measure intent of assessing the level of optimal malnutrition care performed based on the patient's level of malnutrition risk and severity. When the malnutrition risk screening is not performed or a Hospital Dietitian Referral is not documented, the eligible occurrence aligns with the possibility of needing all four observations.