[CQM-7640] Safe Use for Opioids Discharge Disposition Exclusions Created: 01/31/25  Updated: 03/05/25  Resolved: 02/18/25

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

Type: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals Priority: Moderate
Reporter: Whitney Matson Assignee: Mathematica EH eCQM Team
Resolution: Answered Votes: 0
Labels: None

Contact Name: Whitney Matson
Contact Email: wmatson@stjohns.health
Solution: Thank you for your question regarding CMS506v6, Safe Use of Opioids - Concurrent Prescribing. Patients discharged to other acute inpatient facilities, as defined in the value set "Discharge To Acute Care Facility" (2.16.840.1.113883.3.117.1.7.1.87), are excluded. This value set includes community hospitals, tertiary referral hospitals, and acute care hospitals. Patients transferred to a skilled nursing facility, rehabilitation facility, or LTAC hospital are not excluded. A patient discharged to hospice care, "Hospice Care Referral or Admission"(2.16.840.1.113762.1.4.1116.365), is also excluded from the measure, even if palliative or hospice care is not recorded elsewhere during the patient's hospital stay.

Out of the list in your example the following would be excluded by this measure:

*Hospice - Home: 50 Discharged/transferred to Hospice (home)-or alternative setting that is the patient's home such as nursing facility, and will receive in-home hospice services

*Hospice - Medical Facility: 51 Discharged/transferred to Hospice medical facility- patient went to an IP facility that is qualified and the patient is to receive the general IP hospice level of care or hospice respite care. Used also if the patient is discharged from an IP acute care hospital to remain in hospital under hospice care

*Transfer to Other Hosp- Inpt: 02 Discharged/transferred to short-term general hospital for Inpatient Care

We encourage you to map discharge disposition codes to the SNOMEDCT codes consistent with the intent of the SNOMEDCT descriptor.

Please note, patients who are admitted to an inpatient encounter and subsequently transferred to a skilled nursing level of service within the same facility (swing beds) should not be included in the measure. eCQMs are not able to differentiate patients based upon level of service. We encourage you to work with your EHR vendor to remove these patients from the measure for purposes of reporting. We will look into ways to address this in a future version of the measure.
Solution Posted On:
2025 Reporting Period EH/CAH eCQMs:
CMS0071v14
2024 Reporting Period EH/CAH eCQMs:
CMS0506v6
Impact: Increases the rate of patients identified as having concurrent opioid use.
Last Commented Date:

 Description   

We are seeing inpatients with the following discharge dispositions in our data from our EMR.  Should encounters with the following discharge dispositions be excluded? 

  • Swing Bed: 61 - Discharged/transferred within this institution to a hospital based Medicare approved swing bed. This is also used when discharged from an acute care hospital to a CAH swing bed
  • Skilled Nursing Facility: 03 - Discharged/transferred to SNF with Medicare certification in anticipation of covered skilled care.
  • Skilled  Nuring Fac - Plan ACH IP Readmit: 83 - Discharged/transferred to a skilled nursing facility (SNF) with Medicare certification with a planned acute care hospital inpatient readmission
  • Hospice - Home: 50 Discharged/transferred to Hospice (home)-or alternative setting that is the patient's home such as nursing facility, and will receive in-home hospice services
  • Hospice - Medical Facility: 51 Discharged/transferred to Hospice medical facility- patient went to an IP facility that is qualified and the patient is to receive the general IP hospice level of care or hospice respite care. Used also if the patient is discharged from an IP acute care hospital to remain in hospital under hospice care
  • Inpatient Rehab Facility/Unit: 62 Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital
  • Transfer to Other Hosp- Inpt: 02 Discharged/transferred to short-term general hospital for Inpatient Care
  • Cancer Center or Childeren's Hospital: 05 Discharged/transferred to a designated cancer center or children's hospital
  • Long Term Care Hospital: 63 Discharged/transferred to a long term care hospital
  • Psychiatric Facility/Unit: 65 Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital
  • Critical Access Hospital: 66 Discharged/transferred to a Critical Access Hospital (CAH)

 Comments   
Comment by Mathematica EH eCQM Team [ 03/05/25 ]

Thank you for your follow up question. Clinically equivalent services may be mapped to the codes used in the measure’s value sets to satisfy the measure requirements. Unfortunately, we are unable to provide more specific guidance related to the mapping of codes, we recommend that you consult with your EHR vendor and clinical partners. If mapping is conducted, you should maintain documentation in case of a CMS audit.

Comment by Mathematica EH eCQM Team [ 02/20/25 ]

Thank you for the follow-up question. We will review your ticket and provide a response as soon as possible.

Comment by Whitney Matson [ 02/18/25 ]

Can you please let me know where to find the discharge code mapping to SNOMEDCT?  I am a Quality employee trying to understand why my EMR data is putting us in the positions of submitting incorrect data, not someone who knows how to program EMRs.  I need to piece together the evidence to show them that they are doing this incorrectly. I appreciate your help. 

Comment by Whitney Matson [ 02/10/25 ]

Thank you for the update.  I was able to locate the relevant value set and I see it is referencing SNOMEDCT codes.  I work in Quality so I am less familiar with how things with on the EMR technology side. What I can say is that from a clinical quality standpoint, discharge disposition codes have been how we determine the how a patient was discharged for every other quality measure I have worked on previously. This information is readily available to end users in the EMR.  There is no way for Hospitals to validate the accuracy of an eCQM with respect to the patient's discharge status when the measure is specified in terms of SNOMEDCT codes and not discharge disposition. I appreciate your working to bring clarity to the measure. That will help us with our internal improvement efforts. 

Comment by Mathematica EH eCQM Team [ 02/10/25 ]

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 Whitney Matson [ 02/03/25 ]

I am referring to the Safe Use of Opioids Measure that is mandatory for hospitals to submit for the 2024 calendar year. 

Comment by Mathematica EH eCQM Team [ 02/03/25 ]

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

Comment by Mathematica EH eCQM Team [ 02/03/25 ]

Would you be able to clarify which eCQM (measure # and version #) you are referring to? The Safe Use of Opioids measure would be CMS506 - thank you

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