eCQM Impacted – CMS996v6 (Appropriate Treatment for ST-Segment Elevation Myocardial Infarction (STEMI) Patients in the Emergency Department (ED))

Issue – The hospice denominator exclusion logic, as specified, is misaligned with the measure intent. The intent is to exclude encounters in which there is documentation of hospice services in the six months before the start of the ED encounter, or active hospice status at the start of the ED encounter. However, the hospice exclusions, as currently specified, may over-exclude cases with hospice documentation observed on the same day of, but after, an ED encounter with STEMI, as well as cases with hospice diagnosis after an ED encounter with STEMI.