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Global Malnutrition Composite Score

Compare Versions of: "Global Malnutrition Composite Score"

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Measure Information 2024 Reporting Period
Title Global Malnutrition Composite Score
CMS eCQM ID CMS986v2
Short Name

GMCS

NQF Number 3592e
Description

This measure assesses the percentage of hospitalizations for adults aged 65 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each hospitalization, adult inpatients are screened for malnutrition risk, assessed to confirm findings of malnutrition risk or for a hospital dietitian referral order, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, receive a current "moderate" or "severe" malnutrition diagnosis and have a current nutrition care plan performed.

Initial Population

Valid Encounter: Inpatient hospitalizations during the measurement period with length of stay of 24 hours or more among individuals 65 years of age and older at the start of the inpatient encounter

Measure Steward Academy of Nutrition and Dietetics
Measure Scoring Continuous Variable measure
Measure Type Intermediate Clinical Outcome measure
Improvement Notation

Higher score indicates better quality of care

Guidance

This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible hospitalizations and expressed as a percentage. The four populations used to calculate the four components may differ and the measure observations for the four components do not need to be performed sequentially. The initial population are hospitalizations during the measurement period for patients aged 65 years and greater with a length of stay of 24 hours and greater.

Component Measure 1: Inpatient hospitalizations for patients with a current "Malnutrition Risk Screening" performed.

Component Measure 2: Inpatient hospitalizations for patients with a current "Nutrition Assessment" performed from a "Malnutrition Screening At Risk Result" during the current hospitalization or a "Hospital Dietitian Referral" order from a physician or eligible clinician during the current hospitalization.

For Component Measure 1 and Component Measure 2, only report LOINC code '84291-4 Nutrition and dietetics Risk assessment and screening note' when the RD or RDN performs both the "Malnutrition Risk Screening" and "Nutrition Assessment".

Component Measure 3: Inpatient hospitalizations for patients with a current documented "Malnutrition Diagnosis" as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current "Nutrition Assessment Status Severely Malnourished".

Component Measure 4: Inpatient hospitalizations for patients with a current "Nutrition Care Plan" performed as a result of a current "Nutrition Assessment Status Moderately Malnourished" OR current “Nutrition Assessment Status Severely Malnourished”.

"Population 5 Measure Observation TotalMalnutritionComponentsScore" Calculations

-For each hospitalization, Population Criteria 5 represents the subtotal of Measure Observations performed for Population Criteria 1, 2, 3, and 4.

-For the reporting facility, the Population Criteria 5 Aggregate Operator 'Count' counts the number of eligible hospitalizations during the measurement period.

 

"Population 6 Measure Observation TotalMalnutritionCompositeScore as Percentage" Calculations:

-For each hospitalization, Population Criteria 6 represents the sum of performed Measure Observations 1, 2, 3, and 4 divided by the number of clinically eligible denominators.

-For the reporting facility, the Population Criteria 6 Aggregate Operator 'Average' averages the performance of each "TotalMalnutritionCompositeScore as Percentage" across all eligible hospitalizations during the measurement period.

"TotalMalnutritionCompositeScore Eligible Denominators" is always 4 except in the following two instances:

-If a "Malnutrition Risk Screening" was performed and a "Malnutrition Screening Not At Risk Result" was identified AND "Hospital Dietitian Referral" was not ordered, then the "TotalMalnutritionCompositeScore Eligible Denominators" is 1.

-If a "Nutrition Assessment" was performed and a "Nutrition Status Not or Mildly Malnourished" was identified, then the "TotalMalnutritionCompositeScore Eligible Denominators" are 2.

The "TotalMalnutritionCompositeScore Eligible Denominators" equals 4:

-If a "Malnutrition Risk Screening" was performed AND a "Malnutrition Screening At Risk Result" was identified AND a "Nutrition Assessment" was not performed.

-If a "Malnutrition Risk Screening" was not performed AND a "Nutrition Assessment" was not performed.

-If a "Hospital Dietitian Referral" was ordered AND a "Nutrition Assessment" was not performed.

-If a "Nutrition Assessment Status Moderately Malnourished" OR "Nutrition Assessment Status Severely Malnourished" was identified.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter with a length of stay of greater than or equal to 24 hours during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM.

Notes

There is a known issue on CMS986v2. See issue EKI-21 on the ONC eCQM Known Issues Dashboard for details.

Next Version No Version Available
Previous Version No Version Available

Header

  • Revised the narrative of the Initial Population age parameter to start at the beginning of the encounter to align the measure with other eligible hospital measures.

    Measure Section: Description

    Source of Change: ONC Project Tracking System (JIRA): CQM-5829

  • Updated copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Updated references.

    Measure Section: Reference

    Source of Change: Measure Lead

  • Added definitions for the four component measures (i.e., 'Malnutrition Risk Screening', 'Nutrition Assessment', 'Malnutrition Diagnosis', and 'Nutrition Care Plan') to clarify each component's activity and responsible discipline(s).

    Measure Section: Definition

    Source of Change: Measure Lead

  • Revised the narrative of the Initial Population age parameter to start at the beginning of the encounter to align the measure with other eligible hospital measures.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (JIRA): CQM-5829

  • Updated grammar, wording, and/or formatting to improve readability and consistency.

    Measure Section: Multiple Sections

    Source of Change: Annual Update

  • Updated measure language to indicate referral to a hospital dietitian is applicable to meet the measure intent as care for patients who are malnourished.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

  • Added narrative to clarify performance calculations for individual and aggregate scores based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Multiple Sections

    Source of Change: ONC Project Tracking System (JIRA): CQM-5495

Logic

  • Revised the age anchor from the start of the measurement period to the start of the encounter to align the measure with other eligible hospital measures.

    Measure Section: Initial Population

    Source of Change: ONC Project Tracking System (JIRA): CQM-5829

  • Updated the names of CQL definitions, functions, and/or aliases for clarification and to align with the CQL Style Guide.

    Measure Section: Definitions

    Source of Change: Standards/Technical Update

  • Revised the timing attributes for the logic definitions to more accurately represent the timing for the performed measure observations.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Updated measure definitions to allow all clinically eligible activities performed in pre-admission settings to be evaluated in the Measures Observations.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added logic to capture hospitalizations for patients 'not at risk' for malnutrition.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added logic to capture hospitalizations for patients 'not or mildly malnourished'.

    Measure Section: Definitions

    Source of Change: Measure Lead

  • Added logic to capture hospitalizations for patients 'not at risk' for malnutrition.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Added logic to capture hospitalizations for patients 'not or mildly malnourished'.

    Measure Section: Functions

    Source of Change: Measure Lead

  • Updated the sixth measure observation logic in hospitalizations for patients who were screened for malnutrition risk, identified as not at risk for malnutrition, and did not have an order for a hospital dietitian referral during that hospitalization.

    Measure Section: Multiple Sections

    Source of Change: Measure Lead

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Added value set Emergency Department Visit (2.16.840.1.113883.3.117.1.7.1.292) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Hospital Dietitian Referral (2.16.840.1.113762.1.4.1095.91) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Malnutrition Diagnosis (2.16.840.1.113762.1.4.1095.55): Added 3 ICD-10-CM codes (T73.0XXA, T73.0XXD, T73.0XXS) based on terminology update. Deleted 1 ICD-10-CM code (T73.0) based on terminology update. Deleted 2 SNOMED CT codes (190602008, 360549009) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Malnutrition Risk Screening (2.16.840.1.113762.1.4.1095.40) with value set Malnutrition Risk Screening (2.16.840.1.113762.1.4.1095.92) based on applicability of value set and/or OID.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Malnutrition Screening At Risk Result (2.16.840.1.113762.1.4.1095.38): Added 3 SNOMED CT codes (129845004, 445421000124101, 704361005) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (284670008) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Malnutrition Screening Not At Risk Result (2.16.840.1.113762.1.4.1095.34) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Malnutrition Assessment (2.16.840.1.113762.1.4.1095.29) with value set Nutrition Assessment (2.16.840.1.113762.1.4.1095.21) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Nutritional Status Moderately Malnourished (2.16.840.1.113762.1.4.1095.47) with value set Nutrition Assessment Status Moderately Malnourished (2.16.840.1.113762.1.4.1095.44) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Nutrition Assessment Status Not or Mildly Malnourished (2.16.840.1.113762.1.4.1095.48) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Nutrition Care Plan (2.16.840.1.113762.1.4.1095.88) with value set Nutrition Care Plan (2.16.840.1.113762.1.4.1095.93) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Replaced value set Nutritional Status Severely Malnourished (2.16.840.1.113762.1.4.1095.43) with value set Nutrition Assessment Status Severely Malnourished (2.16.840.1.113762.1.4.1095.42) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Added value set Observation Services (2.16.840.1.113762.1.4.1111.143) based on change in measure requirements/measure specification.

    Measure Section: Terminology

    Source of Change: Measure Lead

  • Value set Payer (2.16.840.1.114222.4.11.3591): Added 5 SOP codes (1111, 1112, 142, 344, 141) based on review by technical experts, SMEs, and/or public feedback.

    Measure Section: Terminology

    Source of Change: Measure Lead

Last Updated: Jan 22, 2024