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CMS Measure ID: CMS986v2    Performance/Reporting Period: 2024    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.

Data Elements and coded QDM Attributes contained within the eCQM

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Value Set Description from VSAC
Clinical Focus: This set of values indicates that a malnutrition screening was done by the health care professional.
Data Element Scope: Data elements included in this set indicate an individual has been screened for malnutrition.
Inclusion Criteria: Malnutrition Risk Screening criteria from multiple terminologies are included.
Exclusion Criteria: None.

Constrained to codes in the Malnutrition Risk Screening value set (2.16.840.1.113762.1.4.1095.92)

QDM Datatype and Definition

"Assessment, Performed"

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

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.

Value Set Description from VSAC
Clinical Focus: The clinical focus is for patients who are being assessed in regards to their nutritional status.
Data Element Scope: These are LOINC values which are used in performing a nutritional assessment.
Inclusion Criteria: LOINC terms are used.
Exclusion Criteria: All other clinical terminologies other than LOINC.

Constrained to codes in the Nutrition Assessment value set (2.16.840.1.113762.1.4.1095.21)

QDM Datatype and Definition

"Assessment, Performed"

Data elements that meet criteria using this datatype should document completion of the assessment indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references timing for an assessment that occurs at a single point in time.
  • relevant Period references a start and stop time for an assessment that occurs over a time interval
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

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.

Value Set Description from VSAC
Clinical Focus: Malnutrition diagnosis identified after a nutrition assessment of an individual.
Data Element Scope: These terms are used for malnutrition documentation in Malnutrition Quality Measures.
Inclusion Criteria: Malnutrition diagnosis in individuals 65 years old and over
Exclusion Criteria: Malnutrition diagnosis in individuals under 65 years old

Constrained to codes in the Malnutrition Diagnosis value set (2.16.840.1.113762.1.4.1095.55)

QDM Datatype and Definition

"Diagnosis"

Data elements that meet criteria using this datatype should document the Condition/Diagnosis/Problem and its corresponding value set. The onset dateTime corresponds to the implicit start dateTime of the datatype and the abatement dateTime corresponds to the implicit stop dateTime of the datatype. If the abatement dateTime is not present, then the diagnosis is considered to still be active. When this datatype is used with timing relationships, the criterion is looking for an active diagnosis for the time frame indicated by the timing relationships.

Timing: The prevalencePeriod references the time from the onset date to the abatement date.

Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters in the emergency department (ED).
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter ocurring in the emergency department (ED).
Exclusion Criteria: Excludes concepts that represent services not performed in the emergency department, including critical care and observation services.

Constrained to codes in the Emergency Department Visit value set (2.16.840.1.113883.3.117.1.7.1.292)

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.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts of inpatient hospitalization encounters.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for inpatient hospitalizations.
Exclusion Criteria: No exclusions.

Constrained to codes in the Encounter Inpatient value set (2.16.840.1.113883.3.666.5.307)

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.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for encounters for observation.
Data Element Scope: This value set may use a model element related to Encounter.
Inclusion Criteria: Includes concepts that represent an encounter for observation in the inpatient or outpatient setting.
Exclusion Criteria: No exclusions.

Constrained to codes in the Observation Services value set (2.16.840.1.113762.1.4.1111.143)

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.
Value Set Description from VSAC
Clinical Focus: The purpose of this value set is to represent concepts for hospital dietitian referrals.
Data Element Scope: This value set may use a model element related to referral to a hospital dietitian or dietetics services.
Inclusion Criteria: Hospital-based dietitian or dietetics services referral terms included in extensional value set.
Exclusion Criteria: Hospital-based dietitian or dietetics services referral terms in all other terminologies.

Constrained to codes in the Hospital Dietitian Referral value set (2.16.840.1.113762.1.4.1095.91)

QDM Datatype and Definition

"Intervention, Order"

Data elements that meet criteria using this datatype should document a request to perform the intervention indicated by the QDM category and its corresponding value set.

Timing: The time the order is signed; author dateTime.

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.

Value Set Description from VSAC
Clinical Focus: A Nutrition Care Plan includes assessment, intervention and nutrition diagnosis data which identify an individuals plan.
Data Element Scope: Data elements include those used to assess patient's nutritional status and recommend interventions for optimal nutrition care.
Inclusion Criteria: Data elements are those used by a nutrition and dietetics professional to create a nutrition care plan.
Exclusion Criteria: N/A

Constrained to codes in the Nutrition Care Plan value set (2.16.840.1.113762.1.4.1095.93)

QDM Datatype and Definition

"Intervention, Performed"

Data elements that meet criteria using this datatype should document the completion of the intervention indicated by the QDM category and its corresponding value set.

Timing:

  • relevant dateTime references the time the intervention is performed when the intervention occurs at a single point in time.
  • relevantPeriod references a start and stop time for an intervention that occurs over a time interval. relevantPeriod addresses:
    • startTime - The time the intervention begins.
    • stopTime - The time the intervention ends.
  • author dateTime references the time the action was recorded.
  • Refer to the eCQM expression to determine allowable timings to meet measure criterion.

Notes:

  • Timing refers to a single instance of an intervention. If a measure seeks to evaluate multiple interventions over a period of time, the measure developer should use CQL logic to represent the query request.
  • 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.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Ethnicity value set (2.16.840.1.114222.4.11.837)

QDM Datatype and Definition

"Patient Characteristic, Ethnicity"

Data elements that meet criteria using this datatype should document that the patient has one or more of the ethnicities indicated by the QDM category and its corresponding value set.

Timing: Ethnicity does not have a specific timing. Measures using "Patient Characteristic, Ethnicity" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Categories of types of health care payer entities as defined by the US Public Health Data Consortium SOP code system
Data Element Scope: @code in CCDA r2.1 template Planned Coverage [act: identifier urn:oid:2.16.840.1.113883.10.20.22.4.129 (open)] DYNAMIC
Inclusion Criteria: All codes in the code system
Exclusion Criteria: none

Constrained to codes in the Payer value set (2.16.840.1.114222.4.11.3591)

QDM Datatype and Definition

"Patient Characteristic, Payer"

Data elements that meet criteria using this datatype should document that the patient has one or more of the payers indicated by the QDM category and its corresponding value set.

Timing:

The relevantPeriod addresses:

  • startTime – the first day of insurance coverage with the referenced payer.
  • stopTime – the last day of insurance coverage with the referenced payer.
Value Set Description from VSAC
Clinical Focus: n/a Data Element Scope: n/a Inclusion Criteria: n/a Exclusion Criteria: n/a

Constrained to codes in the Race value set (2.16.840.1.114222.4.11.836)

QDM Datatype and Definition

"Patient Characteristic, Race"

Data elements that meet criteria using this datatype should document the patient’s race.

Timing: Race does not have a specific timing. Measures using "Patient Characteristic, Race" should address the most recent entry in the clinical record.

Value Set Description from VSAC
Clinical Focus: Gender identity restricted to only Male and Female used in administrative situations requiring a restriction to these two categories.
Data Element Scope: Gender
Inclusion Criteria: Male and Female only.
Exclusion Criteria: Any gender identity that is not male or female.

Constrained to codes in the ONC Administrative Sex value set (2.16.840.1.113762.1.4.1)

QDM Datatype and Definition

"Patient Characteristic, Sex"

Data elements that meet criteria using this datatype should document that the patient's sex matches the QDM category and its corresponding value set.

Timing: Birth (administrative) sex does not have a specific timing.

Value Set Description from VSAC
Clinical Focus: This set of values indicates that a patient was found to be at risk for malnutrition after completing a malnutrition screening done by the health care professional.
Data Element Scope: Data included in this set represent that an individual has been evaluated to be at risk for malnutrition.
Inclusion Criteria: Malnutrition At Risk criteria from the SNOMED-CT terminology are included.
Exclusion Criteria: Malnutrition At Risk criteria from other terminologies than SNOMED-CT.

Constrained to codes in the Malnutrition Screening At Risk Result value set (2.16.840.1.113762.1.4.1095.38)

QDM Attribute and Definition

result

The final consequences or data collected from the datatype. results can be used in four ways to express:

  • That a result is present in the electronic record but any entry is acceptable
  • A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units - examples:
    • 100mg/dL for a lab test
    • 140 mmHg for blood pressure
    • as a percentage (actually as a quantity with % as units)
    • as a titer or ratio (e.g., 1:4, 1:80)
  • A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code
  • A result as a dateTime ("Assessment, Performed" and components)
Value Set Description from VSAC
Clinical Focus: This set of values indicates that a patient was found not to be at risk for malnutrition after completing a malnutrition screening done by the health care professional.
Data Element Scope: The intent of this data element is to document individuals not at risk for malnutrition.
Inclusion Criteria: Malnutrition screening which indicates an individual is at risk as indicated by SNOMED-CT.
Exclusion Criteria: Any malnutrition related term which indicates a patient is at risk for malnutrition from other terminology sets than SNOMED-CT.

Constrained to codes in the Malnutrition Screening Not At Risk Result value set (2.16.840.1.113762.1.4.1095.34)

QDM Attribute and Definition

result

The final consequences or data collected from the datatype. results can be used in four ways to express:

  • That a result is present in the electronic record but any entry is acceptable
  • A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units - examples:
    • 100mg/dL for a lab test
    • 140 mmHg for blood pressure
    • as a percentage (actually as a quantity with % as units)
    • as a titer or ratio (e.g., 1:4, 1:80)
  • A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code
  • A result as a dateTime ("Assessment, Performed" and components)
Value Set Description from VSAC
Clinical Focus: Malnutrition assessment of a patient based upon clinically relevant criteria indicates that an individual is moderately malnourished.
Data Element Scope: This set of values indicates that an individual is moderately malnourished.
Inclusion Criteria: Malnutrition codes from SNOMED-CT terminology set which represent an individual is moderately malnourished.
Exclusion Criteria: All other terminologies related to moderate malnutrition except SNOMED-CT are excluded.

Constrained to codes in the Nutrition Assessment Status Moderately Malnourished value set (2.16.840.1.113762.1.4.1095.44)

QDM Attribute and Definition

result

The final consequences or data collected from the datatype. results can be used in four ways to express:

  • That a result is present in the electronic record but any entry is acceptable
  • A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units - examples:
    • 100mg/dL for a lab test
    • 140 mmHg for blood pressure
    • as a percentage (actually as a quantity with % as units)
    • as a titer or ratio (e.g., 1:4, 1:80)
  • A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code
  • A result as a dateTime ("Assessment, Performed" and components)
Value Set Description from VSAC
Clinical Focus: This set of values indicates that a patient was found to be well nourished after completing a nutritional assessment done by the health care professional.
Data Element Scope: Data supporting that an individual is well nourished.
Inclusion Criteria: Data indicating that an individual is well nourished from SNOMED-CT.
Exclusion Criteria: Data indicating that an individual is well nourished from other terminologies.

Constrained to codes in the Nutrition Assessment Status Not or Mildly Malnourished value set (2.16.840.1.113762.1.4.1095.48)

QDM Attribute and Definition

result

The final consequences or data collected from the datatype. results can be used in four ways to express:

  • That a result is present in the electronic record but any entry is acceptable
  • A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units - examples:
    • 100mg/dL for a lab test
    • 140 mmHg for blood pressure
    • as a percentage (actually as a quantity with % as units)
    • as a titer or ratio (e.g., 1:4, 1:80)
  • A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code
  • A result as a dateTime ("Assessment, Performed" and components)
Value Set Description from VSAC
Clinical Focus: Malnutrition assessment of a patient based upon clinically relevant criteria indicates that an individual is severely malnourished.
Data Element Scope: This set of values indicates that a nutritional diagnosis was determined by a health care professional.
Inclusion Criteria: Malnutrition codes from SNOMED-CT terminology set which represent an individual is severely malnourished.
Exclusion Criteria: All other terminologies related to severe malnutrition except those in SNOMED-CT.

Constrained to codes in the Nutrition Assessment Status Severely Malnourished value set (2.16.840.1.113762.1.4.1095.42)

QDM Attribute and Definition

result

The final consequences or data collected from the datatype. results can be used in four ways to express:

  • That a result is present in the electronic record but any entry is acceptable
  • A numerical result is reported directly as a value. Values may be integers or decimal numbers without units, or as a quantity with a value and units - examples:
    • 100mg/dL for a lab test
    • 140 mmHg for blood pressure
    • as a percentage (actually as a quantity with % as units)
    • as a titer or ratio (e.g., 1:4, 1:80)
  • A result that matches one of a specific set of coded concepts in a value set or a code that matches a direct reference code
  • A result as a dateTime ("Assessment, Performed" and components)