[CQM-7800] PC-07 Initial Population Inclusion/Exclusion Created: 04/08/25 Updated: 04/11/25 Resolved: 04/11/25 |
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| Status: | Closed |
| Project: | eCQM Issue Tracker |
| Component/s: | None |
| Type: | Hosp Inpt eCQMs - Hospital Inpatient eCQMs | Priority: | Moderate |
| Reporter: | Lisa Gail Fowler (Inactive) | Assignee: | Augustine Weber |
| Resolution: | Answered | Votes: | 0 |
| Labels: | None | ||
| Issue Links: |
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| Contact Name: | Lisa Gail Fowler | ||||||||
| Contact Email: | lgfowler@saintfrancis.com | ||||||||
| Contact Phone: | 7078158886 | ||||||||
| Institution/Name: | Saint Francis.com | ||||||||
| Solution: | Thank you for your question about CMS1028v2 and CMS1028v3, Severe Obstetric Complications. The Initial Population includes inpatient hospitalizations for patients age >= 8 years and < 65 admitted to the hospital for inpatient acute care who undergo a delivery procedure with a discharge date that ends during the measurement period. The HospitalizationWithEDOBTriageObservation function provides the ability for admissions to also include the ED or OB triage visit(s) with the inpatient delivery encounter if the time of discharge from one visit and the start of the admission occur 1 hour or less of each other. An elective cesarean birth should be a direct inpatient admission at surgery check-in and should be included in the Initial Population. | ||||||||
| Solution Posted On: | |||||||||
| 2025 Reporting Period Hosp Inpt eCQMs: |
CMS1028v3
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| 2024 Reporting Period Hosp Inpt eCQMs: |
CMS1028v2
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| Impact: | Patient with SMM is not being included in the initial population | ||||||||
| Description |
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Our question involves the criteria for a patient to be included in the initial population of the 2024 eCQM CMS 1028v2 and 2025 eCQM CMS1028v3, Severe Obstetrics Complications. The eCQM Measure Flow Diagram states: Delivery Encounter with Age Range: Encounter with Age Range: "Encounter, Performed": "ENCOUNTER INPATIENT" WHERE Age in Years >=8 to <65 at the start of the inpatient encounter that ends during the day of the Measurement Period WITH [Procedure, Performed": DELIVERY PROCEDURES"] starts during day of interval of the hospitalization with prior ED or OB triage visit through the observation visit to discharge. We are focused here on the statement: 'with prior ED or OB triage visit through the observation visit to discharge'. If the patient does not have an ED or OB triage visit but does have ["Procedure, Performed": DELIVERY PROCEDURES"], will/should the patient be included in the Initial Population? Our patient scenario is an elective C-section directly admitted through surgery (no ED, No OB Triage) who did have a qualifying delivery procedure (c-section). This patient is not qualifying to the Initial Population and we are wondering if it is because they did not have an ED or OB Triage visit. We are unsure if the 'with prior ED or OB Triage visit statement is a criteria for inclusion; OR if it simply means that the ED and OB Triage portion of the stay is to be included in the 'Delivery Encounter'. We just need to know if not having an ED or OB triage visit will exclude the patient from the Initial Population, or if this patient should be included. If the intention of the logic is to exclude patients who did not have an ED or OB Triage visit from the Initial Population, can you please provide an explanation that will make sense to clinicians? Many thanks! |
| Comments |
| Comment by Augustine Weber [ 04/09/25 ] |
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Thank you for submitting your question. We will review your ticket and provide a response as soon as possible. |