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Table of Contents:

  • Purpose

  • The difference between Error & Warning Messages

  • Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules

  • Data Accuracy / Source Viewer Error & Warning Messages

  • Schematron Error & Warning Messages

Purpose:  

Below are The Joint Commission specific error and warning messages generated by the edits and Schematron rules executed against each uploaded QRDA I Document.  In addition, those CMS and Health Level Seven (HL7) Schematron rules that are frequently encountered when data is uploaded to the DDS Platform are also included below.

What is the difference between Error & Warning Messages?

QRDA I documents that generate one or more error messages have been rejected and not processed against the eCQM logic.  They are available for you to view within the Source Viewer from the Data Accuracy page.  Since they have not been processed against the eCQM logic, they are not available on the Quality Improvement page and cannot be submitted via the Submit Data page.

QRDA I documents that generated one or more warning messages AND no error messages may be submitted.  We recommend that hospitals review the warning messages to ensure they are not pointing to issues with data capture, data mapping, or QRDA I file generation that can be corrected before the submission deadline.  However, we do realize that hospitals may not have the ability to regenerate QRDA I documents from prior years and so they are unable to correct these warning messages.  If this is your situation, we suggest you continue to review the warning messages and, if needed, work to update your software for the next calendar year and for future years so as to eliminate these warning messages to ensure your measure rates are as accurate as possible.

Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules

Each Data Accuracy message is associated to one or more Source Viewer descriptions.  The Data Accuracy message provides a high-level description of the issue.  Some issues such as "Missing or Invalid Admission Date" can have multiple reasons as to why the issue exists.  The specific reason(s) for the QRDA I Document are detailed within the Source Viewer.

When reviewing data edits within the Source Viewer, if appropriate, the Conformance Number of the edit is displayed.  There are three types of conformance statements with different formats for the CONF number:

  • Joint Commission CONF numbers (TJC-xxxxxx)

  • CMS CONF numbers (CMS_xxxx_xxxx-C01 or xxxx_xxxx-C01)

  • HL7 Clinical Document Architecture (CDA) QRDA Category I Errors (xxxx_xxxx). 

    • Please note that HL7 Conformance numbers are not prefixed with "HL7".  All Conformance numbers without the prefix of "TJC" or "CMS" or a suffix of "C01" are HL7 Conformance numbers.

For more information concerning CMS or HL7 Conformance numbers, see the below reference material:

  • CMS:  Visit the eCQI Resource Center CMS QRDA IG publication page for the documents associated to this year's data.

  • HL7: Visit the HL7 website to obtain the version of the HL7 CDA® R2 IG: QRDA I applicable for this year's data. 

    • The HL7 website may require a HL7 account in order to download the Implementation Guide (IG).

    • The HL7 website header states the current Release number.  Scroll to the bottom of the page to find the Release that is appropriate for this calendar years data.

  • See the eCQM Version Alignment with CMS documentation for information concerning the version of measures, CMS QRDA IG, and HL7 standards that are applicable to this year's data.

Data Accuracy / Source Viewer Error Messages

Table is in order by Message #

TIP: Use Keyboard shortcut to find specific numerical or text strings in the table below, i.e.

“Control” + “F” for Windows
”Command-F” for MAC

Message #
Section/ Element
Status
Data Accuracy Label
(Short Description)
Source Viewer Description
(Long Description)
Expected Behavior in Source Viewer Upon Clicking Error
 Additional Information
100001
Discharge Date
Critical
Missing Encounter Performed Relevant Period High Date
Encounter Performed Relevant Period High Date (effectiveTime/ high) is missing (TJC-100001)
Highlight the encounter performed section, which is missing the 'high' time field, in the source viewer
Validate effective-time 'high' field of all Encounter Performed which includes Inpatient encounter, ED, Observation.
100002
Discharge Date
Critical
Invalid Encounter Performed Relevant Period High Date
Invalid Encounter Performed Relevant Period High Date (effectiveTime/ high) has been provided or it's before 1900. (TJC-100002)
Highlight the encounter performed section which has invalid 'high' time  in the source viewer
Apply all date validation
Do not apply offset, but validate offset format
Valid Date/Time Format:
YYYYMMDDHHMMSSxUUUU
where
YYYY - year Range 1900 to 9999
MM - month - range 01 to 12
DD - day - range 01 to 31 (note: true to month and leap years)
HH - hour - range 0 to 23
MM - minutes - range 0-59
SS - seconds - range 0-59 x - plus or minus sign
UUUU - UTC time shift -1200 thru+1400
100004
Discharge Date
Critical
Invalid Encounter Performed Relevant Period High Date
Encounter Performed Relevant Period High Date (effectiveTime/ high) must be precise to the minute. (TJC-100004)
Highlight the encounter performed section which has invalid 'high' time  in the source viewer
Validate effective-time 'high' value of all Encounter Performed which includes Inpatient encounter, ED, Observation.
100005
Discharge Date
Critical
Encounter Performed Relevant Period High Date is out of range
Encounter Performed Relevant Period High Date  effectiveTime/ high) cannot be greater than current date. (TJC-100005)
Highlight the encounter performed section which has invalid 'high' time  in the source viewer
Validate effective-time 'high' value of all Encounter Performed which includes Inpatient encounter, ED, Observation.
100006
Admit Date
Critical
Invalid Encounter Performed Relevant Period Low Date
Invalid Encounter Performed Relevant Period Low Date  effectiveTime/ low) has been provided or it's before 1900. (TJC-100006)
Highlight the encounter performed section, which has invalid the 'low' time field, in the source viewer
Apply all date validation
Do not apply offset, but validate offset format
Valid Date/Time Format:
YYYYMMDDHHMMSSxUUUU
where
YYYY - year Range 1900 to 9999
MM - month - range 01 to 12
DD - day - range 01 to 31 (note: true to month and leap years)
HH - hour - range 0 to 23
MM - minutes - range 0-59
SS - seconds - range 0-59 x - plus or minus sign
UUUU - UTC time shift -1200 thru+1400
100007
Admit Date
Critical
Missing Encounter Performed Relevant Period Low Date
Encounter Performed Relevant Period Low Date  effectiveTime/ low) is required. (TJC-100007)
Highlight the encounter performed section, which is missing the 'low' time field, in the source viewer
Validate effective-time 'low' field of all Encounter Performed which includes Inpatient encounter, ED, Observation.
100008
DateTime
Critical
Invalid DateTime
Invalid DateTime has been provided. (TJC-100008)
Highlight the template/EffectiveTime with incorrect date
Only validate effectiveTime, Time, and birthTime in QRDA that are listed in TJC xPath Document required by current eCQMs and other than Inpatient Encounter Performed Admit and discharge date.
Check effectiveTime/Time/birthTime's provided values for  accurate format.
Validation for Assessment Performed Result as DateTime.
XPATH location: {AssessmentPerformed}/value @xsi:type="TS": @value
Valid Date/Time Format:
YYYYMMDDHHMMSSxUUUU
where
YYYY - year - range 1900 to 9999
MM - month - range 01 to 12
DD - day - range 01 to 31 (note: true to month and leap years)
HH - hour - range 0 to 23
MM - minutes - range 0-59
SS - seconds - range 0-59 x - plus or minus sign
UUUU - UTC time shift -1200 thru+1400
Do not apply offset- but validate the offset format
100009
Admit Date
Critical
Invalid Encounter Performed Relevant Period Low Date
Encounter Performed Relevant Period Low Date  effectiveTime/ low) value must be precise to the minute. (TJC-100009)
Highlight the encounter performed   section, which has invalid the 'low' time field, in the source viewer
Validate effective-time 'low' value of Encounter Performed which includes Inpatient encounter, ED, Observation.
100010
Admit Date
Critical
Encounter Performed Relevant Period Low Date is out of range
Encounter Performed Relevant Period Low Date  effectiveTime/ low) cannot be greater than current date (TJC-100010)
Highlight the encounter performed  section, which has invalid the 'low' time field, in the source viewer
Validate effective-time 'low' value of all Encounter Performed which includes Inpatient encounter, ED, Observation.
100012
DateTime
Warning
Invalid DateTime
Invalid DateTime has been provided. (TJC-100012)
Highlight the template/EffectiveTime with incorrect date
Only validate effectiveTime, Time, and birthTime in QRDA that are listed in TJC xPath Document but NOT used by current eCQMs.  
Check effectiveTime/Time/birthTime's provided values for  accurate format.
Valid Date/Time Format:
YYYYMMDDHHMMSSxUUUU
where
YYYY - year - range 1900 to 9999
MM - month - range 01 to 12
DD - day - range 01 to 31 (note: true to month and leap years)
HH - hour - range 0 to 23
MM - minutes - range 0-59
SS - seconds - range 0-59 x - plus or minus sign
UUUU - UTC time shift -1200 thru+1400
Do not apply offset- but validate the offset format
100022
Discharge Date
Critical
No Discharge Date in Reporting Period
CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR) and there is NO Inpatient Discharge Date within the reporting period defined in the Reporting Parameters section in the QRDA file. (TJC-100022)
Highlight the first Inpatient Encounter
When CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
Anything on or before 23:59:59 local time on the final day of the reporting period is valid.
Do not apply offset before validation
100023
High@value
Critical
 Event start date after the end date
Event End date is before the Event Start Date. (TJC-100023)
Highlight the template/EffectiveTime with incorrect date
Rejection  for all dates in TJC xPath Document required by current eCQMs.  
apply offset before validation
100024
High@value
Warning
 Event start date after the end date
Event End date is before the Event Start Date. (TJC-100024)
Highlight the template/EffectiveTime with incorrect date
Warning for all dates in TJC xPath Document but not used by current eCQMs.  
apply offset before validation
100025
Encounter ID
Warning
Inconsistent reporting of Inpatient Encounter
CMS Program Name is an Inpatient Program and
there exists inconsistent encounter id, code/codeSystem or effectiveTime in the Inpatient Encounter templates for the same episode, there is a possibility of increased number of EOCs. (TJC-100025)
Highlight the first instance of Inpatient Encounter template for the same episode
For CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
When two inpatient encounters exist, if below condition, we consider they are the same encounter:
*admit and discharge dates are the same
Or
*encounter IDs and extension are the same
If the same inpatient encounters are reported, we only allow for valueset to be different, everything else should be the same.  If any below condition, we trigger this edit:
1. Admit, discharge date or their offsets are different
2. Encounter ID or extension is different
3. encounter code/codeSystem is different
Apply offset before comparison
100026
Encounter ID
Warning
Duplicate Inpatient Encounter Detected
CMS Program Name is an Inpatient Program and two instances of inpatient encounter template are exactly the same. The last instance in the QRDA file will be used for measure evaluation. Remove duplicate encounter template/s to avoid unexpected outcome. (TJC-100026)
Highlight the first instance of Inpatient Encounter template for the same episode
For CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
Admit and discharge dates, encounter code and encounter ID (root and extension) are the same among duplicates.
Apply offset
100027
Patient id
Critical
Invalid QRDA XML file
 
Source Viewer stays blank with no data
Any character which engine is not able to process will trigger this error
(& and foreign numbers and characters are invalid chars).
Following characters are valid for patient_id:
English alphabet and numeric characters, and following special characters:
 ~  !  @  #  $  %  ^  *  (  )  _  +  {  }  |  :  ?  `  -  =  [  ]  \  ;  ‘  .  ,  /  < > and space 
100029
Patient id
Critical
Invalid Patient ID
Invalid Patient ID has been provided. (TJC-100029)
Expectation: Highlight the Patient ID
The patient-id fields cannot be greater than 100 characters OR there are invalid characters.
100031
XML File
Critical
Invalid QRDA XML file
 
Source Viewer stays blank with no data
File is not a valid QRDA XML file
100032
CCN
Critical
Incorrect CCN Reported
The CCN does not match with the CCN associated to the current HCO. (TJC-100032)
Highlight the CCN Number
The CCN is provided. However, the CCN in the document does not match with the CCN associated to the current user.
100035
Header Effective Time
Critical
Missing or invalid Header EffectiveTime
Invalid or null US Realm Date and Time is provided. (TJC-100035)
Highlight the header effectiveTime
US Realm Date and Time under <header> as given in the XPath is null or invalid. 
Valid Date/Time Format:
YYYYMMDDHHMMSSxUUUU
where
YYYY - year - range 1900-9999
MM - month - range 01 to 12
DD - day - range 01 to 31 (note: true to month and leap years)
HH - hour - range 0 to 23
MM - minutes - range 0-59
SS - seconds - range 0-59 x - plus or minus sign
UUUU - UTC time shift -1200 thru+1400
Note: Do not use the template id to find the date, Following the  XPath should be sufficient to find the effective time
Do not apply offset before validation
100036
Encounter ID
Warning
Inpatient encounter outside of the reporting quarter
CMS Program Name is an inpatient Program and there exists an inpatient encounter with discharge datetime outside of the reporting quarter defined in the Reporting Parameter of the QRDA document.  (TJC-100036)
Highlight the Encounter ID
For CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR)
This warning will only trigger when at least one of the inpatient encounter's discharge datetime is outside of the reporting quarter.  
Do not apply offset
100037
Route Code
Warning
A required Medication Route is missing
Route code is missing for an administered medication, and is required by a reported eCQM. (TJC-100037)
Highlight the Medication Template, which is missing the route, AND has negationInd=false or it's negationInd missing AND the code belongs to the value set required by eCQM
Only trigger the warning for those Medications that belong to the value set that eCQM asks for, AND do not have the route and are not negated with negationID=true. (e.g. VTE-1 and VTE-2)
Below listed are Value sets and Codes that need Route code
1. Unfractionated Heparin value set (2.16.840.1.113883.3.117.1.7.1.218) contains the following codes:
 (1361607, 1658717, 1659195, 1659197)
2. Low Dose Unfractionated Heparin for VTE Prophylaxis (2.16.840.1.113762.1.4.1045.39 ) value set contains the following codes :
 (1361226, 1361568, 1361574, 1361577, 1361615, 1361853, 1362831, 1658634, 1658637, 1658647, 1658659, 1659260, 1659263, 1798389, 2121591)
RouteCode ValueSets and codes
A) ["Medication, Administered": "*Low Dose Unfractionated Heparin for VTE Prophylaxis*"] VTEMedication
where VTEMedication.route in "Subcutaneous route":
"Subcutaneous route" valueset 2.16.840.1.113883.3.117.1.7.1.223 and code in this value set- 34206005
B) Medication, Administered": "Unfractionated Heparin"] UnfractionatedHeparin
 where UnfractionatedHeparin.route in "Intravenous route"
"Intravenous route"  valueset 2.16.840.1.113883.3.117.1.7.1.222and codes in this value set- 418114005, 419993007, 47625008
100039
Result Unit
Warning
Unacceptable Unit Reported
There exists an unacceptable unit in the QRDA document. Enter the correct unit as definied in the eCQM logic to avoid an unexpected outcome. (TJC-100039)
Highlight the incorrect/invalid unit
Validate this edit only when below conditions are met-
1. When below specified measures are reported
2. When code is in the below listed Value Sets
3. When result value is provided
Note: DO NOT trigger warning if code is provided from below listed Value Sets but reported measure is not from below specified measures.
List of measures,  required units and data element/Value Sets:
1. eHH-1 and eHH-2 - unit- ‘mg/dL’ for Laboratory Test Performed
"Laboratory Test, Performed: Glucose Lab Test Mass Per Volume" using "Glucose Lab Test Mass Per Volume (2.16.840.1.113762.1.4.1248.34)"
2. ePC-01, ePC-02, ePC-05, ePC-06, ePC-07 - unit- 'wk', 'week' or 'weeks' for Assessment Performed Gestational Age calculation.
For ePC-01, ePC-02, and ePC-07"- Assessment, Performed: Estimated Gestational Age at Delivery" using "Estimated Gestational Age at Delivery (2.16.840.1.113762.1.4.1045.26)"
For  ePC-05 and ePC-06- code "Gestational age--at birth" ("LOINC Code (76516-4)")
3. For ePC-05, ePC-06 - 'g' for Assessment Performed Birth Weight calculation
valueset "Birth Weight" (2.16.840.1.113762.1.4.1029.194)
100041
Header intendedRecipient
Critical
No outpatient measure reported
CMS Program Name is "HQR_OQR", but there is no TJC supported outpatient measure reported in file. (TJC-100041)
Highlight the CMS program name
This edit triggers when QRDA file contains CMS program name as 'HQR_OQR' but no TJC supported outpatient measures are reported.
100042
Header intendedRecipient
Critical
No inpatient measure reported
CMS Program Name is an Inpatient Program (HQR_PI, HQR_IQR, HQR_PI_IQR), but there is no TJC supported inpatient measure reported in file.  (TJC- 100042)
Highlight the CMS program name
This edit triggers when QRDA file contains CMS program name as 'HQR_OQR' but no TJC supported outpatient measures are reported.
100043
Header intendedRecipient
Warning
Inpatient measure reported for outpatient CMS program name
Inpatient measures will not be evaluated when reported CMS program name is 'HQR_OQR' . (TJC- 100043)
Highlight the CMS program name
This warning will only trigger when
*CMS program name as 'HQR_OQR '
*QRDA file contains TJC supported outpatient measures
*And at least one of the TJC supported inpatient measures
100044
Header intendedRecipient
Warning
Outpatient measure reported for inpatient CMS program name
Outpatient measures will not be evaluated when reported CMS program name as ' HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR ' . (TJC- 100044)
Highlight the CMS program name
This warning will only trigger when
*CMS program name as 'HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR '
*QRDA file contains TJC supported Inpatient measures
*And at least one of the TJC supported outpatient measures
100045
Departure Date
Critical
No ED Relevant Period High Date in Reporting Period
CMS Program Name is 'HQR_OQR' and there is NO ED Relevant Period High Date (effectiveTime/ high) within the reporting period defined in the Reporting Parameters section in the QRDA file. (TJC-100045)
Highlight the first Departure Encounter 
When CMS Program Name is an outpatient Program (HQR_OQR)
Anything on or bef
Anything on or before 23:59:59 local time on the final day of the reporting period is valid.
Do not apply offset before validation
100046
Encounter ID
Warning
Inconsistent reporting of Outpatient Encounter
CMS Program Name is an Outpatient Program and
there exists inconsistent encounter id, code/codeSystem or effectiveTime in the Outpatient Encounter templates for the same episode, there is a possibility of increased number of EOCs. (TJC-100046)
Highlight the first instance of Outpatient Encounter template for the same episode
For CMS Program Name is an Outpatient Program (HQR_OQR)
When two outpatient encounters exist, if below condition, we consider they are the same encounter:
*Relevant Period Low Date and Relevant Period High Dates are the same
Or
*encounter IDs and extension are the same
If the same outpatient encounters are reported, we only allow for valueset to be different, everything else should be the same.  If any below condition, we trigger this edit:
1. Relevant Period Low Date and Relevant Period High Date or their offsets are different
2. Encounter ID or extension is different
3. encounter code/codeSystem is different
Apply offset before comparison
100047
Encounter ID
Warning
Duplicate Outpatient Encounter Detected
CMS Program Name is an Outpatient Program and two instances of outpatient encounter template are exactly the same. The last instance in the QRDA file will be used for measure evaluation. Remove duplicate encounter template/s to avoid unexpected outcome. (TJC-100047)
Highlight the first instance of Outpatient Encounter template for the same episode
For CMS Program Name is an Outpatient Program (HQR_OQR)
Relevant Period Low Date and Relevant Period High Date, encounter code and encounter ID (root and extension) are the same among duplicates.
Apply offset
100048
Encounter ID
Warning
Outpatient encounter outside of the reporting quarter
CMS Program Name is an Outpatient Program and there exists an outpatient encounter Relevant Period High Date outside of the reporting quarter defined in the Reporting Parameter of the QRDA document.  (TJC-100048)
Highlight the Outpatient Encounter ID
For CMS Program Name is an Outpatient Program (HQR_OQR)
This warning will only trigger when at least one of the outpatient encounter Relevant Period High Date is outside of the reporting quarter.  
Do not apply offset

Schematron Error Messages

Message #
Section / Element
Status
Data Accuracy Label(Short Description)
Source Viewer Description (Long Description)
Expected Behavior in Source Viewer Upon Clicking Error
Additional Information
CMS_0121
Time Zone
Critical
r-validate_TZ-errors
A Coordinated Universal Time (UTC time) offset should not be used anywhere in a QRDA Category I file or, if a UTC time offset is needed anywhere, then it must be specified everywhere a time field is provided (CONF: CMS_0121)
Highlights the date time field that has the inconsistent UTC time offset
Validate time zone offset for all datetime fields in the QRDA I file.
TJC-0007
Reporting Parameter
Critical
Reporting-Parameters-Act-TJC-errors
This effectiveTime SHALL contain exactly one [1..1] low and exactly one [1..1] high for reporting period start date and end date respectively. Reporting Period must only represent one calendar quarter with valid start and end dates of the quarter (TJC-0007).
Highlights Reporting Parameter section containing invalid start date and end date 
Validates the start and end date of Reporting Period in a given QRDA I file
TJC-0011
CCN
Critical
QDM_based_QRDA_TJC-errors
CCN (Facility CMS Certification Number), if present, SHALL be six to ten characters in length (TJC-0011).
Highlights the header section containing the CCN  which does not satisfy the length requirement
Validate CCN in a given QRDA I file.
TJC-0036
effectiveTime and Time
Warning
r-validate_effectiveTime-TJC-warnings
effectiveTime or time SHALL have either @value or low and high but SHALL NOT have @value and low and high. (TJC-0036)
Highlight the effectiveTime or Time attribute within a template that contains both @value and @low and/or @high
Validates the effectiveTime/Time attribute of all the data elements in a given QRDA I file
TJC-0048
Document Level templateID
Warning
r-DOCUMENT-TJC-US-HEADER-warnings
This document SHALL contain exactly one [1..1] US Realm document level templateId @root="2.16.840.1.113883.10.20.22.1.1" @extension="2015-08-01". CDA data elements will not be validated properly (TJC-0048).
Highlights the US Realm header section, which has incorrect extension
Validates the extension for the US header template ID in a given QRDA I file
TJC-0049
Document Level templateID
Warning
r-DOCUMENT-TJC-QRDA-HEADER-warnings
This document SHALL contain exactly one [1..1] QRDA Category I Framework document level templateId @root="2.16.840.1.113883.10.20.24.1.1" @extension="2017-08-01". QRDA-I data elements will not be validated properly (TJC-0049).
Highlights the QRDA Category I header section, which has incorrect extension
Validates the extension for the QRDA header template ID in a given QRDA I file
TJC-0050
Document Level templateID
Warning
r-DOCUMENT-TJC-QDM-HEADER-warnings
This document SHALL contain exactly one [1..1] QDM-based QRDA document level templateId @root="2.16.840.1.113883.10.20.24.1.2" @extension="2021-08-01". QDM data elements will not be validated properly (TJC-0050)
Highlights the QDM based QRDA header section, which has incorrect extension
Validates the extension for the QDM header template ID in a given QRDA I file
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