Preparing for eCQM Pressure Injury Reporting: What Nurses and Quality Teams Need to Know About Pressure Injuries

Pressure injuries continue to be a major challenge for hospitals, both clinically and financially. With CMS’s introduction of the new eCQM Hospital Harm – Pressure Injury measure, hospitals must now prepare for stricter documentation, coding, and reporting requirements. Bruin Biometrics held an in-depth webinar to help you and your teams be ready for these changes. You can see the full webinar recording here and review the summary of the webinar below.

Why This Measure Matters

Nationally, pressure injuries occur at a rate of 5.4 per 10,000 patient days¹, with 8.4% of acute care patients developing a hospital-acquired injury (HAPI) during their stay. While Stage 2 injuries may appear minor, they still cause harm, delay recovery, and increase readmission risk.

CMS’s decision to include Stage 2 injuries in the new measure reflects a growing emphasis on prevention and health equity. Research shows that patients with darker skin tones are at 60% greater risk for pressure injuries² and four times more likely to die from related causes³. Detecting subtle changes early, before wounds worsen, is a patient safety priority.

Key Program Details

• The measure is elective in 2025 but becomes mandatory in 2028.
• Applies to adults (≥18 years) developing Stage 2–4, unstageable, or deep tissue pressure injuries (DTPI’s).
• Excludes patients with COVID-19 diagnosis.
• Documentation timelines:
  • 24 hours for Stage 2–4 injuries.
  • 72 hours for deep tissue pressure injuries.
• Importantly, if admission follows the emergency department or observation unit within one hour, the documentation clock starts at ED arrival—not inpatient admission.

The Financial Impact of Documentation

Failure to meet reporting requirements can reduce a hospital’s market basket update by 25%, compounding over time. Even a single missed POA designation can mean nearly $10,000 in lost reimbursement per patient case on average. Accurate and timely documentation is critical not only for compliance but also for financial sustainability.

Supporting Accurate Documentation with Technology

Accurate Present on Admission (POA) documentation is central to this measure. However, traditional skin assessments are subjective and may miss early or subtle injuries, particularly in patients with darker skin tones.

The Provizio® SEM Scanner from Bruin Biometrics addresses this gap by:

• Identifying increased risk of pressure injuries 5* days earlier than visual skin assessment
• Identifying both stage one and potential DTPI’s through objective SEM delta (Δ) readings.
• Integrating seamlessly into the EHR through the PIPPA platform, enabling automated data extraction for eCQM reporting.
• Providing defensible, quantifiable evidence that supports nurses, wound care teams, coders, and providers in making accurate POA determinations.

Taking Action Now

Preparing for eCQM reporting should not wait until the measure becomes mandatory. Hospitals can start today by:

• Reviewing policies and workflows for admission assessments.
• Building reports that track ED-to-admission times.
• Ensuring documentation is structured and quarriable in the EHR.
• Establishing cross-disciplinary collaboration between clinical, coding, IT, and administrative teams.
• Implementing technology like the Provizio SEM Scanner to strengthen early detection and documentation.

Conclusion

Pressure injury prevention is a team effort that requires the right policies, processes, and tools. With the new CMS eCQM measure on the horizon, hospitals that prepare now will not only avoid penalties but also improve patient safety and equity.

👉 To learn more about how Bruin Biometrics and the Provizio SEM Scanner can support your organization’s eCQM readiness, reach out to us today.

Refs:
1. Li et al., (2020 )
2. Baumgarten M., et al (2004)
3. Redelings M D., et al. (2005)
* Median