CMS1028v2 and subsequent versions of the eCQM

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    • Type: EH/CAH
    • Resolution: Unresolved
    • Priority: Moderate
    • None
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      To resolve this issue, implementers should take the following steps when reporting CMS1028v3 for the 2025 reporting period, CMS1028v4 for the 2026 reporting period, and subsequent versions of this eCQM:
       
      * Use the most up-to-date eCQM specifications on the eCQI Resource Center (https://ecqi.healthit.gov/) and measure educational resources on Quality Net (https://qualitynet.cms.gov/inpatient/measures/ecqm/resources#tab2).

      * Review the measure specifications to confirm understanding of measure intent.

      * Carefully verify the clinical appropriateness of any mapped codes when reporting this eCQM.

      * Submit PC-07 data to the Hospital Quality Reporting (HQR) system early in the data submission period, as possible, to allow for time to review and make corrections if needed.

      * Review the observed rates of severe obstetric complications and submitted data for this eCQM to identify and correct any errors or anomalies in their facilities’ reported data.
      Show
      To resolve this issue, implementers should take the following steps when reporting CMS1028v3 for the 2025 reporting period, CMS1028v4 for the 2026 reporting period, and subsequent versions of this eCQM:   * Use the most up-to-date eCQM specifications on the eCQI Resource Center ( https://ecqi.healthit.gov/ ) and measure educational resources on Quality Net ( https://qualitynet.cms.gov/inpatient/measures/ecqm/resources#tab2 ). * Review the measure specifications to confirm understanding of measure intent. * Carefully verify the clinical appropriateness of any mapped codes when reporting this eCQM. * Submit PC-07 data to the Hospital Quality Reporting (HQR) system early in the data submission period, as possible, to allow for time to review and make corrections if needed. * Review the observed rates of severe obstetric complications and submitted data for this eCQM to identify and correct any errors or anomalies in their facilities’ reported data.
    • 2024, 2025, 2026

      eCQMs Impacted – CMS1028/PC-07, Severe Obstetric Complications

      Issue – Data from the 2024 reporting period for CMS1028v2 suggest that hospitals are incorrectly mapping codes for routine procedures (e.g., blood typing) to codes for severe maternal morbidity procedures (e.g., blood transfusion).

      These mapping errors may result in the measure overcounting inpatient delivery hospitalizations that meet the numerator criteria, thereby disadvantaging hospitals’ performance rates for this eCQM and inappropriately inflating the national observed complications rate.

            Assignee:
            Unassigned
            Reporter:
            Joelencia Leflore
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              Created:
              Updated: