Data submission requirements

[Steve Daniels]

Hi all, I have a few questions regarding the API:

1. For quality measures under registry submission, is the eligiblePopulationExclusion count reported or only the eligiblePopulationException count? The registry measure specifications from CMS indicate that exclusions are simply removed from the denominator and not called out separately in any of the rate calculations.
   
2. If eligiblePopulationExclusion is not reported for registry submission, does the eligiblePopulation count include or exclude patients with denominator exclusions?
   
3. For stratified quality measures under registry submission, what string should be used for the "stratum" field? Is it the number (e.g. "1", "2", "3") used in the stratum title in the registry measure specification?
   
4. Can attestation-based measures where the answer is "false" can be omitted from the submission?
   

Thanks,

Steve

[j...@patient360.com]

I'm also interested in hearing the answers to these questions, thanks.

[biju joseph]

Hi Steve, 

I do not have a clear answer to all of them, but I can help you on a few. https://cmsgov.github.io/qpp-submissions-docs/schemas# - has explanations on various fields of a measurement. 

For stratum field values, you need to use the stratum name. For measure #392 see - https://github.com/CMSgov/qpp-measures-data/blob/master/measures/measures-data.json#L6335

Regarding "false" for attestation measures, yes can generally be omitted. A true value is needed to earn score for such measures. 

Best regards, 

Biju

[Steve Daniels]

I have received the following information from CMS regarding denominator exclusions in registry submission and would like to confirm that this is consistent with how the submissions API is configured. 

Registry measures are able to remove denominator exclusions prior to formulating the denominator and are not part of the calculations. Claims measures factor denominator exclusions into calculations.

My understanding is that for registry submission, the API fields should be used as follows:

• eligiblePopulation = denominator - denominator exclusions - denominator exceptions
• eligiblePopulationException = denominator exceptions
  
• eligiblePopulationExclusion is omitted for registry measures
• performanceNotMet = performance not met
  
• performanceMet = performance met
  

Thank you,

Steve

[Steve Daniels]

I would like to amend my assumptions below:

• eligiblePopulation = denominator - denominator exclusions (includes denominator exceptions)

• eligiblePopulationException = denominator exceptions
  
• eligiblePopulationExclusion is omitted for registry measures
• performanceNotMet = performance not met
  
• performanceMet = performance met

[steven....@semanticbits.com]

Good Morning!

I would refer to the flow and measure specification for each of the measures that you have a question on. Generally speaking, denominator exclusions are removed prior to creating the eligiblePopulation and numeratorExclusions (eligiblePopulationExclusion) and denominator exceptions (eligiblePopulationException) are removed after checking for performanceMet and should be reported. Please let me know if you have any additional questions!