VTE Diagnostic Test (v2020A)

Specifications Manual for Joint Commission National Quality Measures (v2020A)

Posted: August 1, 2019

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

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Release Notes:
Data Element
Version 2020A

Name:

VTE Diagnostic Test

Collected For:

VTE-6

Definition:

Documentation that a diagnostic test was performed during the hospitalization.

Question:

Is there documentation that a diagnostic test was performed on the day of arrival or anytime during the hospitalization?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation that a diagnostic test was performed on the day of arrival or anytime during the hospitalization.

N (No) There is no documentation that a diagnostic test was performed on the day of arrival or anytime during the hospitalization, or unable to determine from medical record documentation.

Notes for Abstraction:

The time frame for this data element includes patients who had one of the acceptable diagnostic tests performed on arrival or anytime during hospitalization.
Acceptable Examples:
- Patient arrives on 01/01/20XX and documentation indicates a CT of chest with contrast was performed earlier that same day.
- Patient arrived on 01/01/20XX and documentation indicates that the patient was admitted on 01/02/20XX. A VQ scan was performed on 01/04/20XX.
  Unacceptable Example:
- Patient transferred on 01/05/20XX with documentation from a transferring hospital indicating vascular ultrasound was performed on 01/02/20XX.”
If a diagnostic test was performed that is not on the inclusion list, select “No.”
Example:
Patient admitted on 01/01/20XX. 2D Echo done on 01/05/20XX. Physician notes indicate that the test confirmed a PE, select “No.”

Documentation in sources other than radiology reports:

Documentation other than radiology reports must confirm one of the acceptable tests was performed.
Examples:
- Physician Notes: Venous Doppler positive for DVT left popliteal, select “Yes.”
- Emergency Notes: Patient to CT without contrast, select “No.”
The physician/APN/PA documentation must reflect the time frame from arrival to hospital discharge.

Suggested Data Sources:

Admission notes
Consult notes
Discharge summary
Emergency Department record
History and physical
Physician notes
Radiology report

Additional Notes:

Diagnostic testing includes the following:
THIS LIST IS ALL INCLUSIVE

Compression Ultrasound of lower extremities
Venous Ultrasound of lower extremities
Duplex Ultrasound (DUS) of lower extremities
Venous Doppler of lower extremities
Vascular vein mapping of the lower extremities
Computed tomography angiography (CTA) / Angiogram of Chest
Computed tomography angiography (CTA) / Pulmonary Angiogram of Chest
Computed tomography (CT) of thorax (chest) with IV contrast
Computed tomography angiography (CTA) / Angiogram of the abdomen
Computed tomography (CT) of the abdomen/abdominal aorta with IV contrast
Computed tomography (CT) of the pelvis with IV contrast
Computed tomography angiography (CTA) / Angiogram of the pelvis
Computed tomography (CT) of the lower extremity leg veins with IV contrast
CT pulmonary angiogram (CTPA) / CTPA Scan / CT pulmonary embolism (CTPE)
Magnetic resonance imaging (MRI or MRV) of the thorax (chest, cardiac)
Magnetic resonance imaging (MRI or MRV) of the abdomen
Magnetic resonance imaging (MRI or MRV) of the pelvis
Magnetic resonance imaging (MRI or MRV) of the lower extremity leg veins
Nuclear Medicine Pulmonary Scan/ventilation/perfusion (V/Q) lung scan
Pulmonary arteriography/angiography/angiogram
Cavagram/cavogram
Inferior venocavagram
Venography/Venogram of pelvis using IV contrast material
Venography/Venogram of femoral using IV contrast material
Venography/Venogram of other lower extremity veins using IV contrast material

Guidelines for Abstraction:

Inclusion	Exclusion
	Patients with VTE confirmation by only D-dimer tests Patients with VTE diagnosed by tests not listed

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

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