Measure Information Form

Included Populations:
Severe Complications:

• Death
• Transfer to another acute care facility for higher level of care
• ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for Severe Morbidities as defined in Appendix A, Tables:
  • 11.36 Severe Birth Trauma
  • 11.37 Severe Hypoxia/Asphyxia
  • 11.38 Severe Shock and Resuscitation
  • 11.39 Neonatal Severe Respiratory Complications
  • 11.40 Neonatal Severe Infection
  • 11.41 Neonatal Severe Neurological Complications
  • 11.42 Severe Shock and Resuscitation Procedures
  • 11.43 Neonatal Severe Respiratory Procedures
  • 11.44 Neonatal Severe Neurological Procedures
• Patients with Length of Stay greater than 4 days AND an ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for Sepsis as defined in Appendix A, Table 11.45 Neonatal Severe Septicemia
  

Moderate Complications:

• ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for moderate complications as defined in Appendix A, Tables:
  • 11.46 Moderate Birth Trauma
  • 11.47 Moderate Respiratory Complications
  • 11.48 Moderate Respiratory Complications Procedures
• ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table 11.20.2 Single Liveborn Newborn-Vaginal AND Length of Stay greater than 2 days
  OR
  ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table 11.20.3 Single Liveborn Newborn-Cesarean AND Length of Stay greater than 4 days
  AND ANY
  ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for moderate complications as defined in Appendix A, Tables:
  • 11.49 Moderate Birth Trauma with LOS
  • 11.50 Moderate Respiratory Complications with LOS
  • 11.51 Moderate Neurological Complications with LOS Procedures
  • 11.52 Moderate Respiratory Complications with LOS Procedures
  • 11.53 Moderate Infection with LOS
• Patients with Length of Stay greater than 5 days and NO ICD-10-CM Principal Diagnosis Code, ICD-10-CM Other Diagnosis Codes, ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for jaundice or social indications as defined in Appendix A, Tables:
  • 11.33 Neonatal Jaundice
  • 11.34 Phototherapy
  • 11.35 Social Indications

Excluded Populations: None

Data Elements:

• Admission Date
• Discharge Date
• Discharge Disposition
• ICD-10-CM Other Diagnosis Codes
• ICD-10-CM Principal Diagnosis Code
• ICD-10-PCS Other Procedure Codes
• ICD-10-PCS Principal Procedure Code

Included Populations: Single liveborn newborns with ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table Number 11.20.1: Single Liveborn Newborn

Excluded Populations:

• Patients who are not born in the hospital or are part of multiple gestation pregnancies, with no ICD-10-CM Principal Diagnosis Code for single liveborn newborn as defined in Appendix A, Table Number 11.20.1: Single Liveborn Newborn
• ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for birth weight < 2500g as defined in Appendix A, Table 11.12, 11.13, 11.14, 11.15, 11.16, 11.20 OR Birth Weight < 2500g
• Patients who are not term or with < 37 weeks gestation completed
• Patients whose term status or gestational age is missing and birthweight < 3000 gm
• ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for congenital malformations and genetic diseases as defined in Appendix A, Table 11.30 Congenital Malformations
• ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for pre-existing fetal conditions as defined in Appendix A, Table 11.31 Fetal Conditions
• ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for maternal drug use exposure in-utero as defined in Appendix A, Table 11.32 Maternal Drug Use

Data Elements:

• Birth Weight
• Birthdate
• ICD-10-CM Other Diagnosis Codes
• ICD-10-CM Principal Diagnosis Code
• ICD-10-PCS Other Procedure Codes
• ICD-10-PCS Principal Procedure Code
• Term Newborn

• Martin JA, Hamilton BE, Ventura SJ et al. Births: Final data for 2010. National vital statistics reports; vol 61 no1. Hyattsville, MD: National Center for health Statistics. 2012
• Russo, C. A (Thomson Reuters) and Andrews, R.M (AHRQ). Potentially Avoidable Injuries to mothers and Newborns During Childbirth, 2006. HCUP Statistical Brief # 74. June 2009. Agency for Healthcare Research and Quality. Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statsbriefs/sb74.pdf.
• Gregory KD, Fridman M, Shah S et al. Global measures of quality and patient safety-related childbirth outcomes: should we monitor adverse or ideal rates? Am J Obstet Gynecol 2009;200:681.e1-681.e7.
• Profit J, Zupancic JA, Gould JB et al. Implementing pay-for-performance in the neonatal intensive care unit. Pediatrics 2007;119:975-82
• Operative Vaginal Delivery. Practice Bulletin No. 17. American College of Obstetricians and Gynecologists. Obstet Gynecol 2000;1-8
• Shoulder dystocia. ACOG Practice Bulletin No. 40. American College of Obstetrician and Gynecologists. Obstet Gynecol 2002;100:1045-50
• Centers for Disease Control and Prevention. Prevention of Perinatal Group B Streptococcal Disease. MMWR 2010;59 (No. RR 10): 1-36 http://www.cdc.gov/mmwr/pdf/rr/rr5910.pdf
• Wilmink FA, Hukkelhoven CW, Lunshof, S et al. Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7- year retrospective analysis of a national registry.2010 Am J Obstet Gynecol 2002:250.e1-8
• Tita AT, Landon MB, Spong CY et al. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes. N Engl J Med 2009;360(2):111-20
• Hansen AK, Wisborg K, Uldbjerg N. Risk of respiratory morbidity in term infants delivered by elective cesarean section: cohort study. BMJ 2008;336:85
• Spong CY. Defining “Term” pregnancy: Recommendations from the defining “term” pregnancy workgroup. JAMA. 2013 Jun 19;309(23):2445-6.
• Zhang X and Kramer MS. Variations in Mortality and Morbidity by Gestational Age among Infants Born at Term. J Pediatr 2009;154:358-62
• Fleischman AR, Oinuma M and Clark SL. Rethinking the Definition of “Term Pregnancy”. Obstet Gynecol 2010;116(1)136-139
• Clark SL, Miller DD, Belfort MA, et al. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol 2009;200:156.e1-156.e4
• Reddy UM, Bettegowda VR, Dias T et al. Term Pregnancy: A period of Heterogeneous Risk for Infant Mortality. Obstet Gynecol 2011;117:1279-1287
• "Unexpected Complications in Term Newborns.” California Maternal Quality Care Collaborative (CMQCC), 2018, www.cmqcc.org/focus-areas/quality-metrics/unexpected-complications-term-newborns.
  

Measure Algorithm: