Hello,

During testing of C1+C3 QRDA I files, it appears there is some flexibility in terms of "swapping" exclusion criteria. If a patient was expected to be excluded based on the Inpatient+Substance abuse or Mental Health Diagnosis, we were able to have a patient file pass with the use of one of the other OR branch criteria such as Narcolepsy.

Is there any guidance or official stance we could reference should certification testing of a C1 record sample require the Inpatient-driven logic as an expected data criteria? Unlike in the hospice care documentation where there is coding for Inpatient and Ambulatory logic, it doesn't appear the value sets for the exclusion mentioned above have this same flexibility. As an ambulatory EHR system, we feel there should be some type of acceptable substitution to capture coding and information more relevant to an ambulatory system for this measure rather than relying on an Inpatient Encounter and related value set.

Thanks in advance for any input!

Thank you,
Margot