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Table of Contents:
Purpose:
Data Accuracy / Source Viewer Messages for Data Edits and Schematron Rules
Error 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.
Error Messages
Message # | Section/ Element | Status | Data Accuracy Label | Source Viewer 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 |
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 |
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.For 2021, add validation: Assessment Performed Result as DateTime. |
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 | 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. |
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) |
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 | 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) |
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) |
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 | |
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. |
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) |
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
(1361607, 1658717, 1659195, 1659197)
(1361226, 1361568, 1361574, 1361577, 1361615, 1361853, 1362831, 1658634, 1658637, 1658647, 1658659, 1659260, 1659263, 1798389, 2121591)RouteCode ValueSets and codes |
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-
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:
|
100041 | Header intendedRecipient | Critical | No outpatient measure reported | In the QRDA document, reported CMS program name is 'HQR_OQR'. QRDA file did not report any TJC supported outpatient measure. (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 | In the QRDA document, reported CMS program name is 'HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR'. QRDA file did not report any TJC supported inpatient measure. (TJC-100042) | Highlight the CMS program name | This edit triggers when QRDA file contains CMS program name as 'HQR_PI' OR ''HQR_IQR' OR 'HQR_PI_IQR but no TJC supported inpatient measures are reported. |
100043 | Header intendedRecipient | Warning | Inpatient measure reported for outpatient CMS program name | TJC supported 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
|
100044 | Header intendedRecipient | Warning | Outpatient measure reported for inpatient CMS program name | TJC supported 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
|
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) |
100046 | Encounter ID | Warning | Inconsistent reporting of Outpatient Encounter | CMS Program Name is an Outpatient Program and | Highlight the first instance of Outpatient Encounter template for the same episode | For CMS Program Name is an Outpatient Program (HQR_OQR) |
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) |
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) |