In the QDM there is a "Negation Rationale" attribute which seems to be represented in the QRDA-1 as a negationInd attribute and a subordinate Reason template with a value. In some cases, it seems if the relevant CDA element doesn't have this attribute, the whole entry is wrapped in an "act" element. From the QRDA specification, it seems to require that both the subordinate reason template and the attribute flag is set – that is, that you shouldn't have one without the other.

This seems to be contracted by sample data provided from the Cypress project for measure CMS69v5 as one example, data file, "36_THREE N_N GP Adult.xml" which has negationInd="true" attribute on an activity "Intervention, Order: Physical Activity Recommendation" (template 2.16.840.1.113883.10.20.24.3.31) but does not have a corresponding Reason as expected.

If this is not an error, and, a Reason can be omitted – what does the negationInd mean? In particular – what is the "Negation Rationale" as far as the QDM is concerned?