The Procedure, Performed template as defined in the QDM specifies that the procedure has been completed and that it has a start and end time.  The template implies that the procedure can be counted as successfully accomplishing the intended outcome. For example, the tumor was removed, the image was obtained, or the colonoscopy successfully evaluated the patient for colon cancer.

However, an end time does not always imply a successful outcome. In practice, a procedure can be completed and can be unsuccessful. For example, a colonoscopy could be completed but failed to assess the patient for cancer because of patient factors, such as the patient not tolerating the procedure or because the patient’s bowel prep was inadequate. In such a case, the procedure was completed by the usual definition – it was recorded, it had a start and end time, it had a place and a performing provider, and all the other metadata that you would expect. However, the outcome is that the procedure was not successful in screening the patient for cancer, and it must be performed again or replaced with a different evaluation.

Similarly, lab tests can have results that indicate that they were not performed successfully, even though the message is itself a result.

In the charging realm, the CPT terminology enables the documentation of such an outcome by recording a modifier that is attached to the professional charge for the procedure, indicating that the procedure was not successful. Modifier 53 is one such example.

Since its conception, the Procedure, Performed template has included any procedure that is completed, whether successful or not. As such, completed but unsuccessful procedures are including patients in numerators or excluding them, depending on the measure.  Whether this is intentional or not from the measure developer perspective is unclear.  Provider organizations are now recognizing this issue, as when they are evaluated based on claims, procedures with the CPT modifiers or other indicators are not being counted, while in the eCQM context, they are. 

We should consider adding an attribute to the Procedure, Performed template that indicates a successful procedure, or that some other solution to this issue be implemented if it is agreed that one is needed.