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  1. QRDA Issue Tracker
  2. QRDA-1058

EC QRDA III Aggregate Payer count for patient-based and episode-based measures when qualifying encounters have different primary payers

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    • Question/Guidance
    • Resolution: Resolved
    • Moderate
    • QRDA-III Standard
    • None

    Description

      Can you please provide guidance about which payer should be counted for ‘EC QRDA III Aggregate Payer’ when evaluating patient-based and episode-based measures if some of the qualifying encounters have different primary payers?

      Example:

      CMS125 (patient-based measure): Patient is included in the IPP, patient has several qualifying encounters during the measurement period (2 office visits and 1 annual wellness visit). The primary payer for the ‘office visits’ was 'Medicaid', for the ‘Annual Wellness’ visit was 'Private Health Insurance', in which Payer Grouping should this patient be included - Medicaid or Private Health Insurance?

      CMS68 (episode-based measure): 2 qualifying encounters are found during the measurement period. Primary payer for the first qualifying encounter was 'Private Health Insurance', for the second encounter was 'Managed Care Unspecified'. Based on CMS QRDA III IG, 'If an eCQM is episode-based, the count will reflect the patient count rather than the episode count.', which payer should be used for this patient (as the primary payer is different for each encounter?

      Thanks!

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            yanheras Yan Heras
            isbelia Isbelia Briceno
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