[CQM-7231] Guidance on duplicate documentation with different date/times Created: 09/05/24 Updated: 03/06/25 Resolved: 09/13/24 |
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| Status: | Closed |
| Project: | eCQM Issue Tracker |
| Component/s: | None |
| Type: | EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals | Priority: | Moderate |
| Reporter: | Kristen Beatson | Assignee: | Mathematica EH eCQM Team |
| Resolution: | Answered | Votes: | 0 |
| Labels: | None | ||
| Solution: | Thank you for your question. Data captured in clinical documentation should be stored in discrete fields that are mapped on the back-end to codes in the value sets. Please consider a review of QDM v5.6 (https://ecqi.healthit.gov/sites/default/files/QDM-v5.6-508.pdf) for code system and timing considerations for QDM data elements. We hope this helps. |
| Solution Posted On: | |
| 2026 Reporting Period EH/CAH eCQMs: |
CMS1218v1
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| 2025 Reporting Period EH/CAH eCQMs: |
CMS0334v6
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| 2024 Reporting Period EH/CAH eCQMs: |
CMS0334v5
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| Impact: | Incorrect measure results |
| Last Commented Date: |
| Description |
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I'm looking for guidance on how to evaluate data elements that are captured Coding and in clinical documentation. In these scenarios, the clinical documentation is going to have the most accurate date and time, as Coding does not always accurately capture the date and time of procedure. Example: Intubation is a data element in the new PRF eCQM. Intubation captured in Coding doesn't have the true date/time the patient was intubated Intubation captured in clinical or surgical documentation will have the accurate date/time of intubation. How should this be handled since the measure logic evaluates all data with codes from the value set? Are we supposed to exclude the documentation in Coding from evaluation? We see this same issue with C-section in the PC measures. Thanks |
| Comments |
| Comment by Kristen Beatson [ 11/16/24 ] |
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JLeflore Hi, this doesn't really answer my question. The clinical documentation I'm referring to is captured in discreet fields. I guess I'm trying to point out that there will be continued inaccuracies in eCQM results if date/time of dx or procedure is referenced...unless the expectation is that the report submitted exclude certain discreet EHR fields and that clinicians are to document dx / procedures in clinical documentation fields, which is duplicative and increases the burden. Coded Diagnosis and Procedures do not reflect the date/time the dx or procedure occurred and therefore, if evaluated, result in inaccurate results. Is it the expectation that hospitals map ICD codes to clinical documentation and exclude anything documented in coding? |
| Comment by Kristen Beatson [ 09/25/24 ] |
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Matthew I am referencing hh-prf which is 1218. Maybe I'm missing something? |
| Comment by Matthew Dugal [ 09/24/24 ] |
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It is possible this ticket is incorrectly tagged for CMS1218v1. |
| Comment by Joelencia Leflore [ 09/06/24 ] |
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Thank you for submitting your question. We will review your ticket and provide a response as soon as possible. |