CMS Issues Additional Guidance for the “Device, Order not done” Field Submission for VTE-1, VTE-2, and VTE-6 Measures for CY 2016 eCQM Reporting to the Hospital IQR and the Medicare EHR Incentive Programs

The purpose of this announcement is to notify hospitals participating in the Hospital Inpatient Quality Reporting (IQR) Program and the Medicare Electronic Health Record (EHR) Incentive Program for eligible hospitals and critical access hospitals that the Centers for Medicare & Medicaid Services (CMS) has issued additional guidance for the “Device, Order not done” field submission for Venous thromboembolism (VTE) measures: VTE-1, VTE-2, and VTE-6 electronic Clinical Quality Measures (eCQMs) for Calendar Year 2016 reporting.

Issue

There are three eCQMs, identified in the table below, that utilize the “Device, Order not done” Quality Data Model (QDM) datatype in their measure logic to pass or exclude cases that have reasons a VTE prophylaxis device was not ordered per the measure specifications.

Measure Name

Measure Short Name

CMS ID

Venous Thromboembolism Prophylaxis

VTE-1

CMS108v4

Intensive Care Unit Venous Thromboembolism Prophylaxis

VTE-2

CMS190v4

Incidence of Potentially –Preventable Thromboembolism

VTE-6

CMS 114v4

 

Data submitters may have received notice in the feedback reports that their test or production Quality Reporting Document Architecture (QRDA) Category I files received the CDA_SDTC.xsd schema validation error (CMS_0072) when the submitter attempted to submit a QRDA category I file with “Device, Order not done.” This error causes the file to be rejected during the file validation process.

Resolution

Submitters are advised to submit “Device, Applied not done instead of Device, Order not done for the VTE-1, VTE-2, and VTE-6 eCQM measures.

For example, to submit data for “Device, Order not done: Medical Reason” for “Venous foot pumps (VFP)”, please submit as “Device, Applied not done: Medical Reason” for “Venous foot pumps (VFP)”. Utilizing “Device, Applied not done” removes the need for the submitter to institute a workaround within the EHR system in order to pass the schema validation check for the CY 2016 reporting period. See screenshots below showing this example’s submission option.

The eCQM calculation results for VTE-1, VTE-2, and VTE-6 will be the same as if “Device, Order not done” were submitted. It is important to note that this specific guidance is only applicable for VTE-1, VTE-2, and VTE-6 eCQMs for the CY 2016 reporting period.

Image of VTE submission options

The input of data into QRDA files should always be submitted exactly as directed by eCQM definitions and published Implementation Guides provided by CMS or The Joint Commission. When issues arise, we strongly discourage organizations from using any unsanctioned work arounds; such as exchanging elements or modifying data, if a QRDA file is rejected. Instead, any identified issue must be brought to the attention of CMS or The Joint Commission through the ONC CQM Issue Tracker.

For further assistance regarding the information contained in this message, please submit your questions to the ONC CQM Issue Tracker.