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["Diagnoses": "Not Present On Admission Or Documentation Insufficient To Determine"]
Performance/Reporting Period
2025
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for indicating a diagnosis is not present on admission (N) or Documentation insufficient to determine if the condition was present at the time of inpatient admission (U).
Data Element Scope: This value set may use a model element related to Encounter diagnosis.
Inclusion Criteria: Includes PresentOnAdmission concepts that represent diagnosis is not present on admission (N) or Documentation insufficient to determine if the condition was present at the time of inpatient admission (U).
Exclusion Criteria: N/A
Data Element Scope: This value set may use a model element related to Encounter diagnosis.
Inclusion Criteria: Includes PresentOnAdmission concepts that represent diagnosis is not present on admission (N) or Documentation insufficient to determine if the condition was present at the time of inpatient admission (U).
Exclusion Criteria: N/A
Constrained to codes in the Not Present On Admission or Documentation Insufficient to Determine value set (2.16.840.1.113762.1.4.1147.198)
QDM Datatype and Definition
diagnoses
Coded diagnoses/problems addressed during the encounter. The diagnoses attribute has three components:
- diagnosis (code)
- presentOnAdmissionIndicator (code)
- rank (positive integer)
To reference an encounter diagnosis, the expression must include the diagnosis code component. The other components are optional. The expression should only include the presentOnAdmissionIndicator if it is necessary to reference present on admission and should only include the rank if it is necessary to reference principal diagnosis.
The "Encounter, Performed" diagnoses attribute is intended to capture ALL diagnoses, including the principal diagnosis, i.e., all diagnoses addressed during the encounter represented by the diagnosis (code) used in the expression.The presentOnAdmissionIndicator (code) allows the eCQM developer to include criteria about whether each specific "Encounter, Performed" diagnoses was present at the time of admission (an indicator used to evaluate patient safety and adverse events). See presentOnAdmissionIndicator attribute definition and Section A.1.4 for information about using the "Encounter, Performed" diagnoses attribute.
The "Encounter, Performed" diagnoses (rank) replaces the principal diagnosis attribute. To reference a principal diagnosis, eCQM developers should express the "Encounter, Performed" diagnoses with a diagnosis (code) and a rank of 1. See definition of rank in this attribute table.
With an "Encounter, Performed" diagnoses, there is no dependency on the timing of the diagnosis in relation to the encounter.
Use of the "Encounter, Performed": diagnoses attribute component and the "Diagnosis" datatype is redundant for relating the diagnosis to the "Encounter, Performed". The "Encounter, Performed": diagnoses component syntax is preferred.
- Referencing the same diagnosis using "Encounter, Performed" (diagnoses attribute) and "Diagnosis" (datatype) should only occur if the measure must define a specified length of a prevalencePeriod, e.g.,
- The measure must assure that the diagnoses:
- have been present for at least some defined time period before the encounter, and
- were addressed during the "Encounter, Performed"
- The measure must assure that the diagnoses:
eCQMs using this data element:
Last Updated: Jun 26, 2024