[CQM-1235] Principal Diagnosis Code Created: 07/21/14  Updated: 03/02/15  Resolved: 03/02/15

Status: Closed
Project: eCQM Issue Tracker
Component/s: Measure

Type: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals Priority: Minor
Reporter: Kimberly M. Bodine (Inactive) Assignee: Balu Balasubramanyam (Inactive)
Resolution: Duplicate Votes: 0
Labels: Measure, VSharmonization

Issue Links:
Supports
Is supported by QDM-102 Modify the way Principal diagnosis, p... Resolved
Is supported by QDM-106 Enhance Support for Principal Diagnosis Resolved
Solution: QDM-106 is discussing this very topic. Please follow the conversation in the QDM user group and the meeting minutes
Solution Posted On:
2015 Reporting Period EH eCQMs:
CMS111v1/NQF0497, CMS55v1/NQF0495
Impact: Misaligment of eMeasures
Comment Posted On:

 Description   

The majority of eMeasures utilize the inpatient encounter as the beginning date/time for the principal diagnosis. As an example, the Initial Patient Population for eMeasure 107 – Stroke Education includes the principal diagnosis of ischemic or hemorrhagic stroke that starts during inpatient encounter.

• Initial Patient Population =
o AND:
 OR: "Diagnosis, Active: Ischemic Stroke (ordinality: 'Principal Diagnosis')"
 OR: "Diagnosis, Active: Hemorrhagic Stroke (ordinality: 'Principal Diagnosis')"
 starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"

However, eMeasure 55 and 111 include Reporting Stratum 3, which consist of all patients seen in the ED and admitted as an inpatient who have a diagnosis consistent with psychiatric/mental health disorders. The measure specification for these measures requires a principal diagnosis of psychiatric/mental health disorders that starts during the emergency department visit.
• Reporting Stratum 3 =
o AND: "Diagnosis, Active: Psychiatric/Mental Health Patient (ordinality: 'Principal Diagnosis')" starts during "Occurrence A of Encounter, Performed: Emergency Department Visit"

This creates a lack of harmony between the measures in looking at the same data element for two different time frames. In order to better align the measures, a suggestion may be to change the language in inpatient measures to “Starts before or during the inpatient encounter” and leave ED “Starts during the ED encounter” to resolve the issue.

Another greater overarching issue is that diagnosis codes do not have associated dates/times. This coding occurs after the patient discharge and is not correlated to a specific date/time, which hampers the use of this data element to verify the existence of a disease processes during a specified segment of the patient encounter. Please feel free to contact me with any questions.



 Comments   
Comment by Balu Balasubramanyam (Inactive) [ 02/03/15 ]

This topic is currently being discussed in the QDM User group recognizing the discrepancy in representation as well as the intent (billing vs clinical finding). Please follow this discussion in the QDM user group.

Comment by Zahid Butt (Inactive) [ 07/21/14 ]

We also agree there is need for some harmonization but would break this into two separate issues and like to add the following:
The first issue is an inconsistency between two sections of the following clauses.

• Initial Patient Population =
o AND:
 OR: "Diagnosis, Active: Ischemic Stroke (ordinality: 'Principal Diagnosis')"
 OR: "Diagnosis, Active: Hemorrhagic Stroke (ordinality: 'Principal Diagnosis')"
 starts during "Occurrence A of Encounter, Performed: Non-Elective Inpatient Encounter"

(ordinality: 'Principal Diagnosis') is by definition a condition/diagnosis which caused the admission so it has to start before the inpatient encounter even if the diagnosis was "confirmed" only after all the tests/evaluations were completed, possibly even after discharge (as per the eCQM Logic guidance document). Starts "during" the inpatient encounter means it did not start before the start of the inpatient Encounter and strictly speaking could not be a Principal Diagnosis. Currently we assign the Active Diagnosis Start date/time to the Inpatient Encounter Admit Date/time which creates the following problem.
The ED Measures (CMS 55 and 111) Strata are looking for Principal Diagnosis (Psych Value set) that start "during ED Encounters" followed by an Inpatient Encounter. Hospitals are not creating separate Principal Diagnosis for ED Encounters and since the Diagnosis start date is already the Inpatient Encounter Admit Date/Time there is no data returning in these Strata. It seems like the logic in these ED Measures tied to a subsequent Inpatient Encounter would have to reference the Inpatient Principal Diagnosis for these Strata to work.
Any guidance would be appreciated.

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