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  1. QDM Issue Tracker
  2. QDM-220

Present on Admission Attribute - Encounter Diagnosis

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    • Icon: New Feature New Feature
    • Resolution: Fixed
    • Icon: Moderate Moderate
    • QDM 5.5
    • Data Model
    • None
    • Encounter, Performed
    • Adding the POA indicator will allow eCQMs to address hospital-acquired adverse events consistent with some AHRQ measures.

      This item is entered on behalf of MediSolv.

      The Diagnosis Present on Admission (POA) is an indicator assigned to Inpatient Encounter Diagnosis and is used extensively in quality and patient safety measures. The following table lists valid indicators according to the UB-04 standard:

      Y - Diagnosis was present at the time of admission

      N - Diagnosis was not present at the time of admission

      U - Documentation insufficient to determine if condition was present at the time of inpatient admission

      W - Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of inpatient admission

      The QDM Encounter Diagnosis is an attribute of the Encounter data type and does not allow modeling of the POA indicator for eCQM’s in need of this indicator.

      We propose addition of the following two attributes to the QDM Encounter data type in order to address this issue:

      1. Encounter Diagnosis Present on Admission: This attribute would result in a list of Encounter Diagnoses where the POA indicator is = Y
      2. Encounter Diagnosis Not Present on Admission: This attribute would result in a list of Encounter Diagnoses where the POA indicator is = N

      U and W indicators are not included in these two attributes due to their lack of precision for quality reporting.

      https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Coding.html

      The UB-04 Field locators 67 and 67-AQ may represent the fields used for these POA indicators as additions to the diagnosis codes. Confirmation will be helpful.

      The QDM Encounter Diagnosis is an attribute of the Encounter data type and does not allow modelling of the POA indicator for eCQM’s in need of this indicator.

      We propose addition of the following two attributes to the QDM Encounter data type in order to address this issue:

      1. Encounter Diagnosis Present on Admission: This attribute would result in a list of Encounter Diagnoses where the POA indicator is = Y
      2. Encounter Diagnosis Not Present on Admission: This attribute would result in a list of Encounter Diagnoses where the POA indicator is = N

      U and W indicators are not included in these two attributes due to their lack of precision for quality reporting.

       

            eCQM Standards Team eCQM Standards Team
            zbutt@medisolv.com Zahid Butt
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