The Weekly Quality Brief: Hospital Harm eCQMs, Pressure Injury Documentation, and CJRX Program Updates (5/7/26)

The Weekly Quality Brief

• 47 min

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This episode covers questions from a Quality Academy Q&A session focused on eCQM logic, hospital harm measures, CMS reporting requirements, and emerging payment models. eCQM Logic & Validation Clarification of VTE-1 timing requirements when patients enter through the ED or observation before inpatient admission Discussion of “global hospitalization” logic and how encounter timing impacts measure evaluation Recommendations for preparing eCQM management plans and validating mapping throughout the year Considerations for using prior-year performance data when measure specifications and value sets change annually Discussion of structured documentation needs for future measure updates, including STEMI exclusions Perinatal eCQMs Challenges benchmarking PC-02 and PC-07 due to lack of CMS national comparison data Availability of benchmarking tools within Medisolv Encore for electronic hospital measures Hospital Harm Measures Questions regarding opioid-related adverse event logic and low-dose Narcan drips triggering numerator inclusion Discussion of submitting ONC JIRA tickets for edge cases and specification gaps Review of postoperative respiratory failure exclusions and elective encounter logic Clarification that mandatory hospital harm measures are currently proposed in addition to self-selected eCQMs Pressure Injury eCQM Documentation Present-on-admission requirements and timing expectations for pressure injury documentation Use of coding versus clinical documentation for exclusions Required LOINC and SNOMED mappings for pressure injury assessments and staging How contradictory documentation is evaluated within measure logic Falls, AKI, and Coding Logic Review of high-risk AKI exclusions and associated diagnosis/procedure value sets Definitions of moderate and major injury value sets for falls with injury Discussion of present-on-admission coding and its impact on hospital harm measures CMS Reporting & Star Ratings Timing expectations for public reporting of eCQMs and inclusion in Overall Hospital Quality Star Ratings Anticipated preview and release timeline for Failure to Rescue claims-based measure data Clarification of COMP Hip and Knee Medicare Advantage inclusion timelines within Hospital Value-Based Purchasing MIPS Reporting Recommendations for validating provider lists and QRDA generation for system-level MIPS reporting Importance of reconciling QPP provider lists after CMS year-end updates Quality Reporting Operations Discussion of challenges tracking IQR, OQR, IPFQR, and Joint Commission reporting compliance Overview of planned Quality Academy IQR certification training Reminder that webinar recordings and materials are available within the Quality Academy Past Events section Discussion of scheduling conflicts between Quality Academy Q&A sessions and Joint Commission webinars IPFQR & Psychiatric Reporting Proposed retirement of TOB and SUB-2/2A measures within IPFQR Planned product updates to separate SUB-2 and SUB-3 logic within Encore Overview of the IPF Patient Assessment Instrument (PAI) and its connection to future payment reform Expectations for workflow and EHR changes ahead of October 2027 implementation CJRX Model Clarifications regarding ankle replacement inclusion in the CJRX payment model Confirmation that CJRX applies to traditional Medicare only, not Medicare Advantage Explanation of differences between CJRX and the COMP Hip and Knee measure Discussion of bundled payment structure, performance periods, and relationship to the prior CJR model Applicability of CJRX requirements to critical access hospitals and TEAM participants