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Global Malnutrition Composite Score
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Compare Versions of: "Global Malnutrition Composite Score"
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| Measure Information | 2024 Reporting Period | 2025 Reporting Period | 2026 Reporting Period |
|---|---|---|---|
| Title | Global Malnutrition Composite Score | Global Malnutrition Composite Score | Malnutrition Care Score |
| CMS eCQM ID | CMS986v2 | CMS986v4 | CMS986v5 |
| Short Name |
GMCS |
GMCS |
MCS |
| CBE ID* | 3592e | 3592e | 3592e |
| Measure Steward | Academy of Nutrition and Dietetics | Academy of Nutrition and Dietetics | Academy of Nutrition and Dietetics |
| 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. Show more >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. Show less |
This measure assesses the percentage of hospitalizations of 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 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 (1) screened for malnutrition risk or for a hospital dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible provider as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN. Show more >This measure assesses the percentage of hospitalizations of 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 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 (1) screened for malnutrition risk or for a hospital dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed malnutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible provider as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN. Show less |
This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was... appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients are (1) screened for malnutrition risk or for a dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN. Show more >This measure assesses the percentage of eligible encounters of adults aged 18 years and older at the start of the eligible encounter during the measurement period, with a length of stay equal to or greater than 24 hours, who received optimal malnutrition care where care performed was appropriate to the patient's level of malnutrition risk and severity. Malnutrition care best practices recommend that for each eligible encounter, adult inpatients are (1) screened for malnutrition risk or for a dietitian referral order to be placed, (2) assessed by a registered dietitian (RD) or registered dietitian nutritionist (RDN) to confirm findings of malnutrition risk, and if identified with a "moderate" or "severe" malnutrition status in the current performed nutrition assessment, (3) receive a "moderate" or "severe" malnutrition diagnosis by a physician or eligible clinician as defined by the Centers for Medicare & Medicaid Services (CMS), and (4) have a current nutrition care plan performed by an RD/RDN. Show less |
| Measure Scoring | Continuous Variable | Continuous Variable | Continuous Variable |
| Measure Type | Intermediate Clinical Outcome | Intermediate Clinical Outcome | Intermediate Outcome |
| Stratification |
None |
None |
None |
| Risk Adjustment |
None |
None |
None |
| Rationale | The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at-risk of malnutrition or with a hospital dietitian... referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers. The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough physical assessment by registered dietitian nutritionists (RDN). The RDN in turn provides the necessary treatment recommendations to address nutritional status and the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician. The four component measures individually will only provide a fraction of the necessary information on quality of care for patients at-risk of malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at-risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely nursing malnutrition risk screening and hand off to RDNs for appropriate nutritional assessment for patients at-risk of malnutrition during the current hospitalization. For patients identified with a moderate or severe malnutrition status from the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other qualified healthcare professionals and the execution of the nutrition care plan by an RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis and care planning results in better identification of malnourished patients and subsequent improvements in rates of nutrition intervention for the malnourished. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stay, and complications, as well as improved quality of life after hospitalization. Show more >The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at-risk of malnutrition or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers. The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough physical assessment by registered dietitian nutritionists (RDN). The RDN in turn provides the necessary treatment recommendations to address nutritional status and the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician. The four component measures individually will only provide a fraction of the necessary information on quality of care for patients at-risk of malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at-risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely nursing malnutrition risk screening and hand off to RDNs for appropriate nutritional assessment for patients at-risk of malnutrition during the current hospitalization. For patients identified with a moderate or severe malnutrition status from the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other qualified healthcare professionals and the execution of the nutrition care plan by an RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis and care planning results in better identification of malnourished patients and subsequent improvements in rates of nutrition intervention for the malnourished. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stay, and complications, as well as improved quality of life after hospitalization. Show less |
The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a hospital dietitian... referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutritional status utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible provider as defined by CMS. The four measure observations individually will only provide a fraction of the necessary information on quality of care for patients at risk for or with malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely malnutrition risk screening and hand off to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with a moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of malnourished patients and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram, 2017). Show more >The components of this measure are supported by clinical guidance that recommends the following: (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a hospital dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutritional status utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible provider as defined by CMS. The four measure observations individually will only provide a fraction of the necessary information on quality of care for patients at risk for or with malnutrition. For example, knowing which patients have been assessed out of those who were initially identified as at risk, but not knowing if the appropriate proportion of patients were screened upon admission, would be an insufficient assessment of quality of care. Implementation of this measure supports timely malnutrition risk screening and hand off to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with a moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of malnourished patients and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling, and those reported in other studies, also demonstrate the benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram, 2017). Show less |
Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly... longer hospital length of stay (LOS) (Hudson, Chittams, Griffith, & Compher, 2018 and Mosquera et al., 2016) and significantly more patients with malnutrition have a LOS of greater than 7 days when compared to their well-nourished counterparts. Additionally, both higher rates of 30-day readmission and a significantly higher likelihood of 30-day readmission are observed in these patients (Mogensen et al., 2019; Hiller, Shaw, & Fabri, 2016; Mosquera et al., 2016). Lastly, hospitalized adults with malnutrition have an increased likelihood of death within 90 days of discharge (Hiller, Shaw, & Fabri, 2016). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes. The components of this measure are supported by clinical guidance that recommends (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score. High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of patients with malnutrition and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling demonstrates benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram et al., 2016). Show more >Malnutrition has been documented in approximately one-third of patients in developed countries upon admission to the hospital, and, if left untreated, can significantly impact important clinical outcomes (Mogensen et al., 2019). Adult patients with malnutrition have a significantly longer hospital length of stay (LOS) (Hudson, Chittams, Griffith, & Compher, 2018 and Mosquera et al., 2016) and significantly more patients with malnutrition have a LOS of greater than 7 days when compared to their well-nourished counterparts. Additionally, both higher rates of 30-day readmission and a significantly higher likelihood of 30-day readmission are observed in these patients (Mogensen et al., 2019; Hiller, Shaw, & Fabri, 2016; Mosquera et al., 2016). Lastly, hospitalized adults with malnutrition have an increased likelihood of death within 90 days of discharge (Hiller, Shaw, & Fabri, 2016). These consequences demonstrate the importance of addressing malnutrition in hospitalized patients to improve outcomes. The components of this measure are supported by clinical guidance that recommends (1) malnutrition screening for patients admitted into the acute inpatient care setting; (2) nutrition assessment for patients identified at risk for malnutrition or with a dietitian referral order to form the basis for appropriate nutrition interventions; (3) appropriate recognition, diagnosis, and documentation of the nutrition status of a patient in order to (4) address their condition with an appropriate plan of care and communicate patient needs to other care providers (Academy of Nutrition and Dietetics, 2017). The process for risk identification, assessment, diagnosis, and treatment of malnutrition necessitates a multi-disciplinary care team that begins with the identification of an initial risk population for a more thorough assessment by the RD/RDN. The RD/RDN, in turn, provides the necessary treatment recommendations to address nutrition problems utilizing a nutrition diagnosis and care plan, along with the clinical indicators that inform a medical diagnosis of malnutrition completed by a physician or eligible clinician as defined by CMS. The four measure observations individually provide a portion of the necessary information on the quality of care for patients at risk for or with malnutrition. Therefore, the four components are summed and averaged according to a patient’s degree of malnutrition and/or malnutrition risk to determine an encounter-level Malnutrition Care Score. High performance on this measure requires malnutrition risk screening and/or referral to RDNs for appropriate nutrition assessment for identified patients during the current hospitalization. For patients identified with moderate or severe malnutrition by the nutrition assessment, best practice also recommends a medical diagnosis by a physician or other eligible clinician and the execution of the nutrition care plan by an RD/RDN. Evidence demonstrates that implementing a standardized protocol for screening, assessment, diagnosis, and care planning results in better identification of patients with malnutrition and subsequent improvements in rates of associated nutrition interventions. Outcomes modeling demonstrates benefits to patient outcomes, including reduced risk of 30-day readmissions, length of hospital stays, and complications, as well as improved quality of life after hospitalization (Sriram et al., 2016). Show less |
| Clinical Recommendation Statement | American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) clinical guidelines on nutrition screening, assessment, and intervention in adults, Screening for nutrition risk is suggested for hospitalized patients. (A.S.P.E.N., 2011). This guideline places nutrition assessment and...screening in the context of intervention as part of nutrition care. Screening those individuals at risk of malnutrition is the first step in nutrition care as nutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Nutrition assessment is suggested for all patients who are identified to be at malnutrition risk by nutrition screening. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition support intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition support intervention in patients identified assessment as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. Show more >American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) clinical guidelines on nutrition screening, assessment, and intervention in adults, Screening for nutrition risk is suggested for hospitalized patients. (A.S.P.E.N., 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk of malnutrition is the first step in nutrition care as nutrition risk, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Nutrition assessment is suggested for all patients who are identified to be at malnutrition risk by nutrition screening. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition support intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition support intervention in patients identified assessment as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. Show less |
American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, et al., 2011). This guideline places nutrition...assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plants in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. Show more >American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, et al., 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plants in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. Show less |
American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, Compher, Druyan, & ASPEN Board of Directors, 2011). ...This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. Show more >American Society for Parenteral and Enteral Nutrition (ASPEN) clinical guidelines on nutrition screening, assessment, and intervention in adults indicate that screening for nutrition risk is suggested for hospitalized patients (Mueller, Compher, Druyan, & ASPEN Board of Directors, 2011). This guideline places nutrition assessment and screening in the context of intervention as part of nutrition care. Screening those individuals at risk for malnutrition is the first step in nutrition care as risk for malnutrition, identified by nutrition screening, is associated with longer length of hospital stay, complications, and mortality. Malnutrition screening is also a predictor of mortality risk. Malnourished patients, identified by nutrition assessment tools, have more complications and longer hospitalizations than do patients with optimal nutrition status. Such patients, identified by nutrition assessment tools, have more infectious and noninfectious complications, longer hospital length of stay, and greater mortality. Nutrition intervention is recommended for patients identified by assessment as at risk for malnutrition or malnourished. Nutrition intervention with associated monitoring and evaluation plans in patients identified as at risk for malnutrition or malnourished improves clinical outcomes. Nutrition interventions and their associated monitoring and evaluation plans in malnourished patients are associated with improved nutrition status, nutrient intake, physical function, and quality of life. Hospital readmissions, inpatient length of stay, and complications were reduced with increased nutrition support interventions. Show less |
| Improvement Notation |
Higher score indicates better quality of care |
Higher score indicates better quality of care. |
Increased score indicates improvement |
| Definition | Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from the nutrition interventions. For the inpatient or acute care... setting, the Malnutrition Risk Screening is performed by a nursing professional, Registered Dietitian (RD), or Registered Dietitian Nutritionist (RDN). Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s). For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician/eligible clinician based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations and interventions that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, and is documented by the RD or RDN. Show more >Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from the nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening is performed by a nursing professional, Registered Dietitian (RD), or Registered Dietitian Nutritionist (RDN). Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s). For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician/eligible clinician based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations and interventions that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, and is documented by the RD or RDN. Show less |
Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting,... the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN. Show more >Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN. Show less |
Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting,... the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN. Show more >Malnutrition Risk Screening - the process of identifying and referring those individuals and populations who are at risk for nutrition-related problems, are appropriate for nutrition care services, and would benefit from nutrition interventions. For the inpatient or acute care setting, the Malnutrition Risk Screening can be completed by any eligible healthcare clinician as defined by local, state and federal guidelines. Nutrition Assessment - a systematic approach for collecting, classifying, and synthesizing important and relevant data to describe nutritional status related nutritional problems, and their causes. This assessment includes review of the "whole" patient and evaluates the anthropometrics (i.e., body measurements and proportions), biochemical data (i.e., laboratory findings), clinical observations, and diet history (also known as 'ABCD'). For the inpatient or acute care setting, the Nutrition Assessment is performed by a RD or RDN. Malnutrition Diagnosis - a documented diagnosis that identifies and describes a specific nutrition problem(s) that can be resolved or improved through nutrition intervention(s), monitoring, and evaluation. For the inpatient or acute care setting, the Malnutrition Diagnosis is identified by the physician or other eligible clinician as defined by CMS based on the scope of practice regulations within the respective state, commonwealth, or territory of care delivery. Nutrition Care Plan - a documented plan based on information collected during the Nutrition Assessment of individualized nutrition recommendations, interventions, and monitoring and evaluation plans that are directed toward resolving the Malnutrition Diagnosis by altering or eliminating the nutrition etiology. The Nutrition Care Plan may encompass the interventions of Food and Nutrient Delivery, Nutrition Education, Nutrition Counseling, Coordination of Nutrition Care, and Population Based Nutrition Action, along with a plan for monitoring and evaluation, and is documented by the RD or RDN. Show less |
| 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. Show more >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. Show less |
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. 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 among individuals 65 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more >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. 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 among individuals 65 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less |
This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible encounters 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. This eCQM is an episode-based measure. An episode is defined as each eligible encounter with a length of stay of greater than or equal to 24 hours among individuals 18 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show more >This measure is constructed of four clinically eligible components that are aggregated as an arithmetic average of eligible encounters 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. This eCQM is an episode-based measure. An episode is defined as each eligible encounter with a length of stay of greater than or equal to 24 hours among individuals 18 years of age and older at the start of the inpatient encounter. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. Show less |
| 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 |
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. |
Eligible encounters during the measurement period with length of stay of 24 hours or more among individuals 18 years of age and older at the start of the inpatient encounter |
| Measure Population |
Equals Initial Population |
Equals Initial Population |
Equals Initial Population |
| Measure Population Exclusion |
None |
None |
Encounters with a discharge disposition for hospice care or with a hospice care order during the inpatient qualifying encounter |
| Next Version | No Version Available | ||
| Previous Version | No Version Available | No Version Available |
*Verify active CBE endorsement on the CMS certified consensus-based entity’s PQM website
General eCQM Information
Specifications
There is a known issue on CMS986v4. See issue EKI-37 on the ONC eCQM Known Issues Dashboard for details.
Additional Resources for CMS986v4
*Note there may be more tickets for CMS986v4 in the eCQM Tracker - ASTP/ONC Project Tracking System (Jira). Only tickets tagged with their associated CMS measure ID appear.
Use the eCQM Tracker to open new issues regarding eCQM implementation. Log in required.
General eCQM Information
Header
Updated the eCQM version number.
Measure Section:
eCQM Version Number
Source of Change:
Annual Update
Changed all references from NQF to CBE to identify the consensus-based entity role.
Measure Section:
CBE Number
Source of Change:
Annual Update
Updated measure developer from Avalere Health to the Academy of Nutrition and Dietetics.
Measure Section:
Measure Developer
Source of Change:
Measure Lead
Updated Description and Measure Observation text to reflect update in timing of malnutrition diagnosis to overlap with inpatient encounter and better align with clinical practice.
Measure Section:
Description
Source of Change:
Measure Lead
Updated copyright.
Measure Section:
Copyright
Source of Change:
Annual Update
Added a timing clause to include linked emergency and observation encounters associated with the inpatient encounter and update the narrative to reflect the logic.
Measure Section:
Rate Aggregation
Source of Change:
Measure Lead
Added the possible values for population criteria 5 and 6 to assist the users with comprehension.
Measure Section:
Rate Aggregation
Source of Change:
Measure Lead
Removed guidance for use of LOINC code '84291-4' from the header sections as it is no longer being used.
Measure Section:
Rate Aggregation
Source of Change:
Measure Lead
Renamed denominator function from 'Eligible Denominator' to 'Eligible Occurrence' to better align with naming conventions.
Measure Section:
Rate Aggregation
Source of Change:
Measure Lead
Updated Rate Aggregation and Guidance descriptions to better reflect the logic and clarify aggregate measure calculations.
Measure Section:
Rate Aggregation
Source of Change:
Measure Lead
Removed guidance for use of LOINC code '84291-4' from the header sections as it is no longer being used.
Measure Section:
Guidance
Source of Change:
Measure Lead
Updated Rate Aggregation and Guidance descriptions to better reflect the logic and clarify aggregate measure calculations.
Measure Section:
Guidance
Source of Change:
Measure Lead
Updated Description and Measure Observation text to reflect update in timing of malnutrition diagnosis to overlap with inpatient encounter and better align with clinical practice.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Added the possible values for population criteria 5 and 6 to assist the users with comprehension.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Added the phrase 'or a Hospital Dietitian Referral' to align with changes in logic and measure intent.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Renamed denominator function from 'Eligible Denominator' to 'Eligible Occurrence' to better align with naming conventions.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Added a timing clause to include linked emergency and observation encounters associated with the inpatient encounter and updated the narrative to reflect the logic.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Added the phrase 'or a Hospital Dietitian Referral' to align with changes in logic and measure intent.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Updated the Eligible Occurrences (prior Eligible Denominators) description to support alignment with measure intent and improve clarity.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Added the phrase 'but the 'Nutrition Assessment' was not performed' for the Eligible Occurrences definitions.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Updated grammar, wording, and/or formatting to improve readability and consistency.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Updated references and measure header to reflect current evidence and new or updated literature.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Logic
Updated measure logic to allow counting the Hospital Dietitian Referral Order as completion of Measure Observation 1 (Malnutrition Risk Screening) to better align with clinical practice.
Measure Section:
Initial Population
Source of Change:
Measure Lead
Added logic to prioritize 'Not at Risk' result in Malnutrition Risk Screening to prevent inaccurate calculations.
Measure Section:
Numerator
Source of Change:
Measure Lead
Updated logic to prioritize 'Not/Mildly Malnourished' result in Nutrition Assessment to prevent inaccurate calculations.
Measure Section:
Numerator
Source of Change:
Measure Lead
Updated the eligible occurrence function from 4 to 2 in encounters where a Nutrition Assessment was not completed to more fairly score performance.
Measure Section:
Measure Observations
Source of Change:
Measure Lead
Added logic to prioritize 'Not at Risk' result in Malnutrition Risk Screening to prevent inaccurate calculations.
Measure Section:
Definitions
Source of Change:
Measure Lead
Removed redundant variable names and substituted Qualifying Encounter with Inpatient Hospitalization to support simplifying the logic and align with measure intent.
Measure Section:
Definitions
Source of Change:
Measure Lead
Renamed value set to 'Payer Type' to more accurately reflect the contents and intent of the value set.
Measure Section:
Definitions
Source of Change:
Standards/Technical Update
Updated logic definition of Malnutrition Diagnosis from 'starts during' to 'overlaps' with the current inpatient encounter to better align with clinical practice.
Measure Section:
Definitions
Source of Change:
Measure Lead
Updated logic to prioritize 'Not/Mildly Malnourished' result in Nutrition Assessment to prevent inaccurate calculations.
Measure Section:
Definitions
Source of Change:
Measure Lead
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
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Definitions
Source of Change:
Annual Update
Renamed 'Eligible Denominator' to 'Eligible Occurrence' to better align with naming conventions.
Measure Section:
Functions
Source of Change:
Measure Lead
Updated the version number of the Measure Authoring Tool (MAT) Global Common Functions Library to v8.0.000 and the library name from 'MATGlobalCommonFunctions' to 'MATGlobalCommonFunctionsQDM.'
Measure Section:
Functions
Source of Change:
Annual Update
Updated the eligible occurrence function from 4 to 2 in encounters where a Nutrition Assessment was not completed to more fairly score performance.
Measure Section:
Functions
Source of Change:
Measure Lead
Updated the eligible occurrence function from 4 to 2 in encounters where a Nutrition Assessment was not completed to more fairly score performance.
Measure Section:
Functions
Source of Change:
Measure Lead
Added logic to prevent scoring of additional measure components when Not At Risk result present in Malnutrition Screening to ensure correct calculations.
Measure Section:
Multiple Sections
Source of Change:
ONC Project Tracking System (JIRA): CQM-6285
Updated measure logic to allow counting the Hospital Dietitian Referral Order as completion of Measure Observation 1 (Malnutrition Risk Screening) to better align with clinical practice.
Measure Section:
Multiple Sections
Source of Change:
Measure Lead
Updated logic to stop additional observation performance measurement when Not At Risk result (for Malnutrition Screening) or Not Mild Malnutrition result (for Nutrition Assessment) to ensure correct calculations.
Measure Section:
Multiple Sections
Source of Change:
ONC Project Tracking System (JIRA): CQM-6142
Value Set
The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.
Updated Malnutrition Risk Screening value set to include normative responses.
Measure Section:
Terminology
Source of Change:
Measure Lead
Grouping value set Malnutrition Diagnosis (2.16.840.1.113762.1.4.1095.55): Added 4 ICD-10-CM codes (M62.84, R62.7, R64, E63.9) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 ICD-10-CM code (E45) based on review by technical experts, SMEs, and/or public feedback. Added 18 SNOMED CT codes based on review by technical experts, SMEs, and/or public feedback. Deleted 1 SNOMED CT code (302872003) based on terminology update.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Malnutrition Risk Screening (2.16.840.1.113762.1.4.1095.92): Added 1 LOINC code (101807-6) based on review by technical experts, SMEs, and/or public feedback. Deleted 1 LOINC code (84291-4) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Malnutrition Screening Finding of At Risk Result (2.16.840.1.113762.1.4.1095.38) removed as a standalone value set in the measure based on terminology update; the value set is now included in the Malnutrition Screening Finding of At Risk Result grouping value set that was added (OID: 2.16.840.1.113762.1.4.1095.89).
Measure Section:
Terminology
Source of Change:
Annual Update
Added value set Malnutrition Screening Finding of At Risk Result (OID 2.16.840.1.113762.1.4.1095.89), which includes two extensional value sets: Malnutrition Screening Finding of At Risk Result (SNOMED; OID 2.16.840.1.113762.1.4.1095.38) and Malnutrition Screening Finding of At Risk Result (LOINC; 2.16.840.1.113762.1.4.1095.94).Malnutrition Screening Finding of At Risk Result (SNOMED; OID 2.16.840.1.113762.1.4.1095.38) was previously included in measure as a standalone extensional value set; since last measure publication, the value set was renamed and experienced code changes.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set (2.16.840.1.113762.1.4.1095.34): Renamed to Malnutrition Screening Finding of Not At Risk Result based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Malnutrition Screening Finding of Not At Risk Result (2.16.840.1.113762.1.4.1095.34): Added 1 LOINC code (LA33699-2) based on terminology update. Deleted 1 SNOMED CT code (36823005) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set Nutrition Assessment (2.16.840.1.113762.1.4.1095.21): Added 1 LOINC code (101819-1) based on terminology update. Deleted 1 LOINC code (84291-4) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Added value set Nutrition Assessment Status Finding of Moderately Malnourished (OID 2.16.840.1.113762.1.4.1095.47), which includes two extensional value sets: Nutrition Assessment Status Finding of Moderately Malnourished (SNOMED; OID 2.16.840.1.113762.1.4.1095.44) and Nutrition Assessment Status Finding of Moderately Malnourished (LOINC; OID 2.16.840.1.113762.1.4.1095.98) 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 Finding of Severely Malnourished (OID 2.16.840.1.113762.1.4.1095.43), which includes two extensional value sets: Nutrition Assessment Status Finding of Severely Malnourished (SNOMED; OID 2.16.840.1.113762.1.4.1095.42) and Nutrition Assessment Status Finding of Severely Malnourished (LOINC; OID 2.16.840.1.113762.1.4.1095.97) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Added value set Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished (2.16.840.1.113762.1.4.1095.96), which includes two extensional value sets: Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished (SNOMED; OID 2.16.840.1.113762.1.4.1095.48) and Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished (LOINC; OID 2.16.840.1.113762.1.4.1095.95) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Nutrition Assessment Status Finding of Moderately Malnourished (2.16.840.1.113762.1.4.1095.44) removed as a standalone value set in the measure; the value set is now included in the Nutrition Assessment Status Finding of Moderately Malnourished grouping value set that was added (OID: 2.16.840.1.113762.1.4.1095.47) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished (2.16.840.1.113762.1.4.1095.48) removed as a standalone value set in the measure; the value set is now included in the Nutrition Assessment Status Finding of Well Nourished or Not Malnourished or Mildly Malnourished grouping value set that was added (OID: 2.16.840.1.113762.1.4.1095.96) based on terminology update.
Measure Section:
Terminology
Source of Change:
Annual Update
Value set Nutrition Assessment Status Finding of Severely Malnourished (2.16.840.1.113762.1.4.1095.42) removed as a standalone value set in the measure; the value set was renamed and is now included in the Nutrition Assessment Status Finding of Severely Malnourished grouping value set that was added (OID: 2.16.840.1.113762.1.4.1095.43) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set Nutrition Care Plan (2.16.840.1.113762.1.4.1095.93): Added 1 SNOMED CT code (1279742004) based on terminology update. Added 1 SNOMED CT code (445101000124100) based on review by technical experts, SMEs, and/or public feedback. Deleted 10 SNOMED CT codes (182922004, 418995006, 61310001, 441041000124100, 225372007, 229912004, 384760004, 435691000124100, 448556005, 709564003) based on review by technical experts, SMEs, and/or public feedback.
Measure Section:
Terminology
Source of Change:
Measure Lead
Value set (2.16.840.1.114222.4.11.3591): Renamed to Payer Type based on recommended value set naming conventions.
Measure Section:
Terminology
Source of Change:
Annual Update
Last Updated: Aug 05, 2025