[CQM-6490] 2024 ePC-05 Specification Missing Logic for 37 Weeks of Greater EGA Based on Coding Created: 10/05/23  Updated: 02/28/24  Resolved: 10/20/23

Status: Closed
Project: eCQM Issue Tracker
Component/s: None

Type: Hosp Inpt eCQMs - Hospital Inpatient eCQMs Priority: Moderate
Reporter: Elizabeth Butler Assignee: Joelencia Leflore
Resolution: Answered Votes: 0
Labels: None

Attachments: PNG File TJC Website - eCQM issues to ONC Issue Tracking System.png     Microsoft Word ePC-05 2024 Specification Missing Criteria for Evaluating 37 Weeks or Greater Based on Coding.docx    
Contact Name: Elizabeth Butler
Contact Email: elizabeth.butler@oracle.com
Contact Phone: 8166681260
Institution/Name: Oracle Health onbehalf of CommonSpirit Health System
Solution: Thank you for your question about CMS334v5/PC-02 Cesarean Birth and CMS1028v2/PC-07 Severe Obstetric Complications. Please submit any questions related to PC-05, PC-06, and PC-01 to The Joint Commission WIKI platform https://manual.jointcommission.org/Home.

To provide a response to your questions for CMS334v5 and CMS1028v2:

The codes in the value sets “37 to 42 Plus Weeks Gestation” (OID: 2.16.840.1.113762.1.4.1110.68) and “20 to 42 Plus Weeks Gestation” (OID: 2.16.840.1.113762.1.4.1110.67) cannot be used for the other measures you have flagged because they represent maternal codes (as opposed to codes for newborns). We hope this helps.
Solution Posted On:
2024 Reporting Period Hosp Inpt eCQMs:
CMS0334v5, CMS1028v2
Impact: 2024 ePC-05 eCQM specification does not evaluate EGA at Delivery consistently with how other measure (ePC-02 and ePC-05) evaluate EGA. This could cause encounters to inappropriately show as NOT MET in the report that should be excluded.
Last Commented Date:

 Description   

For 2024 TJC updated the ePC-02 and ePC-07 specifications were updated to evaluate EGA at Delivery via Diagnosis Coding. 

 

When ePC-05 evaluates encounters for EGA >=37 weeks, it should look at coding also to be consistent with the 2024 updates on the other Perinatal Care eCQMs.

This valueset represents EGAs at Delivery += 37 weeks.  https://vsac.nlm.nih.gov/valueset/2.16.840.1.113762.1.4.1110.67/expansion/Latest) 

 

 

 Comments   
Comment by Joelencia Leflore [ 10/30/23 ]

Thank you for your follow-up question. If you have questions about CMS334/PC-02 and/or CMS1028/PC-07, both CMS program measures, ONC Jira is the correct platform for these questions. Please note that PC-05 and PC-01 are not CMS program eCQMs-- for questions about these measures, please submit to https://manual.jointcommission.org/Home. We hope this helps.

Comment by Elizabeth Butler [ 10/20/23 ]

The TJC website provided as the solution (https://manual.jointcommission.org/Home) says if your question is relating to CMS eCQMs then Go to the ONC Isssue Tracking System and links to this website. Screenshot attached.   Is there somewhere other than here on the ONC Issue Tracking Perinatal Care eCQM issues should be submitted? 

Comment by Joelencia Leflore [ 10/16/23 ]

We continue to investigate the issue noted in your ticket and will provide a response as soon as we are able. Thank you for your patience.

Comment by Joelencia Leflore [ 10/06/23 ]

Thank you for submitting your question. We will review your ticket and provide a response as soon as possible.

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