Clarification on CMS32v5 and identifying “Occurrence A” in the Initial Patient Population.

We have a test QRDA file from Cypress containing two separate Emergency Department Visits which fall into the Initial Patient Population, and could be assigned as “Occurrence A”.

Initial Patient Population definition: “Occurrence A of Encounter, Performed: Emergency Department Visit" during "Measurement Period”

After this logic, we still have two ER Visits which are applicable.

When applying this occurrence to the subsequent Measure Population Definition (based on section 2.8.5 of the QDM manual)
• AND NOT: "Occurrence A of Encounter, Performed: Emergency Department Visit" <= 6 hour(s) ends before or concurrent with start of "Encounter, Performed: Encounter Inpatient"

The earliest ER Visit does not fall within six hours of the Inpatient Encounter (passes the logic), but the second ER Visit does (fails the logic). Cypress is stating that this file should pass the measure logic, and because of how we are evaluating the occurrences, it is failing the measure logic.

From the documentation I have read on defining occurrences, I have not found any documentation on the proper way to determine “Occurrence A” in an instance such as this. We are looking for further guidance on this. We have referenced the QDM manual (version 4.1.2), but do not see this specific type of instance addressed.

We have attached the file in question.