eCQM Diagnosis Qualification Clarification

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    • Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs
    • Resolution: Answered
    • Priority: Moderate
    • Component/s: None
    • None
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      Thank you for your inquiry regarding the CMS STK VTE, and HH eCQMs.

      1. Is the intent of rank=1 to qualify the final professional coding and not physician documentation?
      Response: Rank defines a position in a hierarchy for diagnoses and rank=1 indicates “Principal Diagnosis”.

      2. If so, and rank is not specified for a data element, should all sources of diagnosis documentation qualify?
      Response: The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR.

      3. In some cases, physician documentation is incorrect and is qualifying inappropriately whereas the final coding/claims would be more accurate. Is the intent across measures to qualify diagnosis based on what is accurate per customer?
      Response: You will need to work with your organization, IT resources, and EHR vendor to best assess where the data is appropriately documented. The assessment can include a review of clinician workflow, documentation, as well as how the encounters are processed once completed. Organizations should provide education on how to appropriately document within their system as well as fine tune picklists and data sources when appropriate.

      4. If always a particular source (i.e. professional coding) is more accurate, could further information be documented in the QDM or measure specific specifications to indicate?
      Response: The QDM does not prescribe the source of where diagnosis data can be found in the EHR.
      Please find below additional resources that may assist with implementation:

      More information regarding the QDM data model can be found at this link: https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf

      The eCQM Data element Repository provides QDM attributes and definitions per measure by element: https://ecqi.healthit.gov/mc-workspace-2/data-element-repository

      The eCQM implementation checklist is also a great resource: https://ecqi.healthit.gov/ecqm-implementation-checklist
      Show
      Thank you for your inquiry regarding the CMS STK VTE, and HH eCQMs. 1. Is the intent of rank=1 to qualify the final professional coding and not physician documentation? Response: Rank defines a position in a hierarchy for diagnoses and rank=1 indicates “Principal Diagnosis”. 2. If so, and rank is not specified for a data element, should all sources of diagnosis documentation qualify? Response: The QDM does not prescribe the source of diagnosis data in the EHR. Diagnoses may be found in a patient’s problem list, encounter diagnosis list, claims data, or other sources within the EHR. 3. In some cases, physician documentation is incorrect and is qualifying inappropriately whereas the final coding/claims would be more accurate. Is the intent across measures to qualify diagnosis based on what is accurate per customer? Response: You will need to work with your organization, IT resources, and EHR vendor to best assess where the data is appropriately documented. The assessment can include a review of clinician workflow, documentation, as well as how the encounters are processed once completed. Organizations should provide education on how to appropriately document within their system as well as fine tune picklists and data sources when appropriate. 4. If always a particular source (i.e. professional coding) is more accurate, could further information be documented in the QDM or measure specific specifications to indicate? Response: The QDM does not prescribe the source of where diagnosis data can be found in the EHR. Please find below additional resources that may assist with implementation: More information regarding the QDM data model can be found at this link: https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf The eCQM Data element Repository provides QDM attributes and definitions per measure by element: https://ecqi.healthit.gov/mc-workspace-2/data-element-repository The eCQM implementation checklist is also a great resource: https://ecqi.healthit.gov/ecqm-implementation-checklist
    • cms0986v6
    • CMS0104v15, CMS0108v15, CMS1017v3
    • CMS0071v15, CMS0072v14, CMS0104v14, CMS0108v14, CMS0190v14, CMS0334v7, CMS0506v8, CMS0816v5, CMS0819v4, CMS0826v3, CMS0832v3, CMS0871v5, CMS0986v3, CMS0986v5, CMS1017v1, CMS1017v2, CMS1028v4, CMS1074v3, CMS1218v1, CMS1218v2
    • CMS0104v13
    • CMS0104v12

      From the QDM resources, CQL, and Guidance sections of the specifications, what sources of diagnoses to qualify (EHR physician documentation vs. final professional coding) is needing clarification.  In some measures like VTE and STK (below),  EncounterDiagnoses.rank = 1 is indicated. In other instances like HH-FI it is not (below).

      1. Is the intent of rank=1 to qualify the final professional coding and not physician documentation? 
      2. If so, and rank is not specified for a data element, should all sources of diagnosis documentation qualify?
      3. In some cases, physician documentation is incorrect and is qualifying inappropriately whereas the final coding/claims would be more accurate. Is the intent across measures to qualify diagnosis based on what is accurate per customer?
      4. If always a particular source (i.e. professional coding) is more accurate,  could further information be documented in the QDM or measure specific specifications to indicate?
      5. If this is already outlined within one of the following QDM links, please point me to where this is indicated for future reference.

      Condition/Diagnosis/Problem QDM category - https://ecqi.healthit.gov/mcw/2026/qdm-category/conditiondiagnosisproblem.html

      Diagnosis QDM attribute - https://ecqi.healthit.gov/mcw/2026/qdm-attribute/diagnoses.html

      "Diagnosis" QDM Datatype - https://ecqi.healthit.gov/mcw/2026/qdm-dataelement/diagnosis.html

       

      Examples:

      VTE-1

      Encounter With Principal Diagnosis Of Mental Disorder Or Stroke

      •   VTE."Encounter With Age Range And Without VTE Diagnosis Or Obstetrical Conditions" QualifyingEncounter
            where exists ( QualifyingEncounter.diagnoses EncounterDiagnoses
                where EncounterDiagnoses.rank = 1
                  and ( EncounterDiagnoses.code in "Mental Health Diagnoses"
                      or EncounterDiagnoses.code in "Hemorrhagic Stroke"
                      or EncounterDiagnoses.code in "Ischemic Stroke"))

      STK-2

      TJC.Ischemic Stroke Encounter

      •   "Non Elective Encounter With Age" NonElectiveEncounterWithAge
            where exists ( NonElectiveEncounterWithAge.diagnoses Diagnosis
                where Diagnosis.code in "Ischemic Stroke"
                  and Diagnosis.rank = 1)

      HH-FI

      Encounter with a Fall Diagnosis

      •   "Initial Population" QualifyingEncounter
            where exists ( QualifyingEncounter.diagnoses FallDiagnosis
                where FallDiagnosis.code in "Inpatient Falls")

            Assignee:
            Mathematica EH eCQM Team
            Reporter:
            Becky Crellin
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              Created:
              Updated:
              Resolved:
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