LVSD (v2020A)

Specifications Manual for Joint Commission National Quality Measures (v2020A)

Posted: August 1, 2019

Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

Print this page

Home » LVSD

Release Notes:
Data Element
Version 2020A

Name:

LVSD

Collected For:

ACHF-01, ACHFOP-01, ACHFOP-02, ACHFOP-03

Definition:

Left ventricular systolic dysfunction (LVSD) is an impairment of left ventricular performance. An ejection fraction (EF) is an index of left ventricular systolic function (LVSF) and reflects the proportion of blood ejected during each ventricular contraction compared with the total ventricular filling volume.

Question:

Is the left ventricular systolic function (LVSF) documented as an ejection fraction (EF) of <40% or ≤35% or a narrative description consistent with moderate or severe systolic dysfunction?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

1 LVSF is documented as an EF ≤35%.

2 LVSF is documented as an EF equal to 36-39%.

3 LVSF is documented as an EF equal to 40%.

4 Documentation of a narrative description consistent with moderate or severe systolic dysfunction.

5 EF or a narrative description consistent with moderate or severe systolic dysfunction is not documented, or EF ≥ 41% or unable to determine from medical record documentation.

Notes for Abstraction:

Utilize documentation from the most recent test/procedure performed (i.e. test or procedure performed closest to discharge).
- If a test/procedure was not performed to determine EF, other documentation within the medical record may be used (e.g. H&P, progress report, consolation report).
  - Test and procedure report results take priority over non-report sources (e.g. progress notes).
- Final findings from a test or procedure report take priority over preliminary findings.
  - If documentation is not labeled as a "preliminary result”, assume it is a final result.
  - Conclusion section of a report takes priority over other sections. Consider the “Impression,” “Interpretation,” and “Final Diagnosis” sections as equivalent with the “Conclusion” section.
  - Results from in-hospital test or procedure filed in the medical record after the patient’s discharge can be utilized.
  - If the most recent test/procedure does not include documentation of an EF utilize the second most recent test or procedure (i.e. test/procedure performed closest to discharge), and so on.
  - Documentation from a test/procedure performed prior to arrival for this hospital or outpatient encounter maybe utilized, if no testing/procedures were performed during this encounter. Use results from the pre-arrival test known to be most recent (i.e. closest to hospital or outpatient arrival).
  - If the EF is documented as a range, document lowest value (e.g. EF between 38% and 41%. Assign 38%).
Narrative descriptions
- Use worst narrative description with severity specified.
- Select 4 if description is synonymous with term from Inclusion list A.
- Select 5 if description with severity specified is NOT synonymous with term from Inclusion List A (e.g., normal, mild, preserved).
- Use narrative description without severity specified. Select 4 if description is synonymous with term from Inclusion list B. Otherwise, select 5.

Suggested Data Sources:

Consultation notes
History and physical
Progress notes
Discharge summary
Procedure notes
Outpatient medical record

Additional Notes:

Guidelines for Abstraction:

Inclusion

Exclusion

Inclusion list A: Moderate/severe LVSD

Biventricular dysfunction described as marked, moderate, moderate-severe, severe, significant, substantial, or very severe
Biventricular heart failure described as moderate or severe
Ejection fraction or left ventricular ejection fraction (LVEF) described as low, poor, or very low
Endstage cardiomyopathy
Hypokinesis described as diffuse, generalized, or global AND marked, moderate, moderate-severe, severe, significant, substantial, or very severe
Left ventricular (LV) akinesis described as marked, moderate, moderate-severe, severe, significant, substantial, or very severe
Left ventricular (LV) hypokinesis described as marked, moderate, moderate-severe, severe, significant, substantial, or very severe in one or more segments of left ventricle
Left ventricular dysfunction (LVD), left ventricular systolic dysfunction (LVSD), or systolic dysfunction described as marked, moderate, moderate-severe, severe, significant, substantial, or very severe
Left ventricular function (LVF), left ventricular systolic function (LVSF), or systolic function described as low, poor, or very low
Systolic failure described as marked, moderate, moderate-severe, severe, significant, substantial, or very severe AND not described as right ventricular

Inclusion list B: LVSD — Severity not specified

Biventricular dysfunction where severity is not specified
Ejection fraction or left ventricular ejection fraction (LVEF) described as abnormal, compromised, decreased, depressed, diminished, impaired, or reduced
Hypokinesis described as diffuse, generalized, or global where severity is not specified
Left ventricular (LV) hypokinesis described as involving the entire left ventricle
Left ventricular dysfunction (LVD), left ventricular systolic dysfunction (LVSD), or systolic dysfunction where severity is not specified
Left ventricular function (LVF), left ventricular systolic function (LVSF), or systolic function described as abnormal, compromised, decreased, depressed, diminished, impaired, or reduced
Systolic failure where severity is not specified AND not described as right ventricular

Moderate or severe systolic dysfunction

Any term in Inclusion list A or B described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
Any term in Inclusion list A or B described as mild-moderate

Specifications Manual for Joint Commission National Quality Measures (v2020A)
Discharges 01-01-20 (1Q20) through 6-30-20 (2Q20)

LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION (“CPT®”)

You, your employees and agents are authorized to use CPT® only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. You acknowledge that the American Medical Association (“AMA”) holds all copyright, trademark and other rights in CPT®.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT® for resale and/or license, transferring copies of CPT® to any party not bound by this Agreement, creating any modified or derivative work of CPT®, or making any commercial use of CPT®. License to use CPT® for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt.

U.S. Government Rights This product includes CPT® which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The American Medical Association does not agree to license CPT® to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. The American Medical Association reserves all rights to approve any license with any Federal agency.

Disclaimer of Warranties and Liabilities. CPT® is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to the implied warranties of merchantability and fitness for a particular purpose. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the (AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this product is with The Joint Commission, and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this product.

This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by clicking below on the button labeled “accept”.