CMS55 Patients meeting Measure Population but not Measure Observation

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    • Type: Implementation Guidance
    • Resolution: Done
    • Priority: Moderate
    • Component/s: None
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      Thank you for the question. Yes, the intent is to have a measure observation that is computational. However, if all the data is not provided in order to perform the calculation, then it is possible that the encounter will meet the measure population and error at the measure observation calculation.
      The ED departure time logic referenced in the ticket is assessing for the hospital location code of the ED encounter that occurred within an hour of the inpatient encounter.​ The hospital location code can be found in the “Emergency Department Visit” valueset using "2.16.840.1.113883.3.117.1.7.1.292.”
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      Thank you for the question. Yes, the intent is to have a measure observation that is computational. However, if all the data is not provided in order to perform the calculation, then it is possible that the encounter will meet the measure population and error at the measure observation calculation. The ED departure time logic referenced in the ticket is assessing for the hospital location code of the ED encounter that occurred within an hour of the inpatient encounter.​ The hospital location code can be found in the “Emergency Department Visit” valueset using "2.16.840.1.113883.3.117.1.7.1.292.”

      eCQM Logic and Guidance has the following statement - "Measure Observations that describe the computation to be performed over the members of the Measure Population". This seems to imply to me that there should be something computable if the patient meets the population. But this is not always the case. In measure CMS 55v7, it appears entirely possible for a patient encounter to meet the Measure Population without having a valid Measure Observation. Specifically, if the encounter has a facility location arrival and departure time but does not have a facility location code, the patient will not meet the measure observation.

      Is this the intended behavior of these measures? Our philosophy has been to "let the measures do the work", but is there some additional check we should be doing here?

      Thank you,
      Matthew Dugal

            Assignee:
            Yan Heras
            Reporter:
            Matthew Dugal
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