["Encounter, Performed": "Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital observation status if the discharge is on other than the initial date..."]

Performance/Reporting Period

2023

Direct Reference Code

Constrained to 'Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital observation status if the discharge is on other than the initial date of observation status. To report services to a patient designated as observation status or inpatient status and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])' CPT code

QDM Datatype and Definition

"Encounter, Performed"

Data elements that meet criteria using this datatype should document that the encounter indicated by the QDM category and its corresponding value set is in progress or has been completed.

The "Encounter, Performed" participant references the primary participant.

Previous versions of QDM included an attribute principal diagnosis, defined as the condition that, after study, was determined to be the principal cause of the admission. QDM version 5.6 addresses that concept using the diagnosis rank=1.

Timing:

The relevantPeriod addresses:
- startTime - The time the encounter began (admission time).
- stopTime - The time the encounter ended (discharge time).
author dateTime references the time the action was recorded.
Refer to the eCQM expression to determine allowable timings to meet measure criteria.

Notes:

negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod.
The locationPeriod is an attribute of the attribute facility location that addresses:
- startTime - the time the patient arrived at the location. The time the encounter began (admission time).
- stopTime - the time the patient departed from the location.

eCQMs using this data element:

CMS136v12 - Follow-Up Care for Children Prescribed ADHD Medication (ADD)

CMS146v11 - Appropriate Testing for Pharyngitis

CMS154v11 - Appropriate Treatment for Upper Respiratory Infection (URI)

QDM Attributes

relevantPeriod

relevantPeriod addresses the time between the start of an action to the end of an action. Each QDM datatype using relevantPeriod defines specific definitions for the start and stop time for the action listed.

Note: negation rationale indicates a one-time documentation of a reason an activity is not performed. Negation of QDM datatype-related actions for a reason always use the author dateTime attribute to reference timing and must not use relevantPeriod